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The document outlines the importance of environmental and facility safety in healthcare environments, focusing on minimizing risks for patients and staff by adhering to local laws and regulations. It details strategies for managing risks, including training staff, conducting regular drills, and ensuring compliance with safety codes related to fire and equipment. The document emphasizes the need for ongoing risk assessments and the establishment of effective emergency response plans.

Environment
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25-Sep-22 1
25-Sep-22 2
• ‫هي‬ ‫الحيز‬ ‫الذى‬ ‫يعيش‬ ‫فيه‬ ‫اإلنسان‬ ‫و‬ ‫يمارس‬ ‫نشاطه‬ • ‫عرف‬ ‫القانون‬ ‫المصري‬ ‫البيئة‬ ‫بأنها‬ " ‫المحيط‬ ‫الحيوي‬ ‫الذي‬ ‫يشمل‬ ‫الكائنات‬ ‫الحية‬ ‫و‬ ‫ما‬ ‫يحويه‬ ‫من‬ ‫مواد‬ ‫و‬ ‫ما‬ ‫يحيط‬ ‫بها‬ ‫من‬ ‫هواء‬ ‫و‬ ‫ماء‬ ‫و‬ ،‫تربة‬ ‫و‬ ‫ما‬ ‫يقيمه‬ ‫اإلنسان‬ ‫من‬ ‫منشات‬ ‫فبذلك‬ ‫تشمل‬ ‫البيئة‬ ‫داخل‬ ‫المستشفي‬ ‫جميع‬ ‫االشخاص‬ ‫و‬ ‫المعدات‬ ‫و‬ ‫التجهيزات‬ ‫و‬ ‫االنشاءات‬ ‫وما‬ ‫يحيط‬ ‫بها‬ 25-Sep-22 3
‫المعدات‬ ‫و‬ ‫اآلالت‬ . ‫االنفجار‬ ‫و‬ ‫الحرائق‬ . ‫نقل‬ ‫وسائل‬ ‫المبنى‬ ‫طبيعة‬ ‫الحركة‬ ‫سامة‬ ‫معادن‬ . ‫أبخرة‬ ‫و‬ ‫غازات‬ . ‫و‬ ‫مذيبات‬ . ‫مبيدات‬ ‫حرارة‬ , ‫رطوبة‬ , ‫ضغط‬ , ‫اشعة‬ ‫األجر‬ . ‫اإلنسانية‬ ‫العالقات‬ . ‫الدعم‬ ‫األسرى‬ ‫و‬ ‫االجتماعي‬ ‫طفيليات‬ ‫و‬ ‫فيروسات‬ ‫و‬ ‫بكتريا‬ 25-Sep-22 4
 ‫يجب‬ ‫الهدف‬ ‫لهذا‬ ‫نصل‬ ‫لكي‬ ‫إدارة‬ ‫الطبية‬ ‫والمعدات‬ ‫واألجهزة‬ ‫المرافق‬ ‫إلى‬ ‫تسعى‬ ‫فعالة‬ ‫بطريقة‬ : .1 ‫واإلصابات‬ ‫الحوادث‬ ‫وقوع‬ ‫منع‬ .2 ‫والمخاطر‬ ‫األخطار‬ ‫ومكافحة‬ ‫خفض‬ .3 ‫آمنة‬ ‫ظروف‬ ‫على‬ ‫الحفاظ‬ . 25-Sep-22 5
 ‫المحلية‬ ‫اللوائح‬ ‫و‬ ‫للقوانين‬ ‫طبقا‬ ‫المهنية‬ ‫الصحة‬ ‫و‬ ‫السالمة‬ ‫أعمال‬ ‫تنظم‬ : .1 ‫قانون‬ 12 ‫لسنة‬ 2003 ( ‫الخامس‬ ‫الباب‬ ) .2 ‫قرار‬ 134 ‫لسنة‬ 2003 .3 ‫قرار‬ 211 ‫لسنة‬ 2003 .4 ‫قانون‬ 59 ‫لسنة‬ 1960 ( ‫المؤينة‬ ‫األشعة‬ . ) .5 ‫المصري‬ ‫الحريق‬ ‫كود‬ 25-Sep-22 6
 Environmental and Facility Safety (EFS) in healthcare facilities aims at minimizing potential risks for patients, visitors, staff, and buildings through compliance with local laws, regulations, fire, and building codes for providing a safe and secure work environment. 25-Sep-22 7
 ‫والمتابعة‬ ،‫والتدريب‬ ،‫التخطيط‬ ‫تشمل‬ ‫أن‬ ‫يجب‬ ‫الفعالة‬ ‫اإلدارة‬ : .1 ‫تخطيط‬ ‫الالزمة‬ ‫والموارد‬ ‫األجهزة‬ ‫و‬ ‫الخدمات‬ ‫و‬ ‫المرافق‬ ‫ادارة‬ ‫لكيفية‬ .2 ‫تدريب‬ ‫على‬ ‫العاملين‬ :  ‫اإلدارة‬ ‫خطط‬ ‫تطبيق‬  ‫المخاطر‬ ‫تقليل‬ ‫كيفية‬  ‫خطر‬ ‫تشكل‬ ‫التي‬ ‫األماكن‬ ‫عن‬ ‫تقرير‬ ‫وتقديم‬ ‫المتابعة‬ ‫كيفية‬ . .3 ‫المتابعة‬ ‫أولويات‬ ‫وتحديد‬ ‫األداء‬ ‫لتقييم‬ ‫معايير‬ ‫باستخدام‬ ‫التحسين‬ 25-Sep-22 8
• Facility Management JCI • Environment & Facility Safety Egyptian ACC. • ISO 14000 family • Environmental management ISO • Occupational Health & Safety standards OSHA 25-Sep-22 9
.1 ‫واألمن‬ ‫السالمة‬ Safety & Security .2 ‫والمخلفات‬ ‫الخطرة‬ ‫المواد‬ Hazardous Material & Waste .3 ‫الحرائق‬ ‫من‬ ‫األمان‬ Fire Safety .4 ‫الطبية‬ ‫األجهزة‬ Medical Equipment .5 ‫الخدمات‬ ‫و‬ ‫المرافق‬ ‫نظم‬ Utility Management .6 ‫المعمل‬ ‫في‬ ‫االمان‬ ‫برنامج‬ Laboratory Safety Prog .7 ‫االشعاعي‬ ‫االمان‬ ‫برنامج‬ Radiation Safety Prog 10 25-Sep-22
 ‫خطة‬ ‫توجد‬ ............ ‫االداء‬ ‫ومؤشرات‬ ‫واالستراتيجية‬ ‫والمجال‬ ‫األهداف‬ ‫تشمل‬ :  ‫االشعاع‬ ‫من‬ ‫االمان‬  ‫المعمل‬ ‫في‬ ‫االمان‬  ‫العمل‬ ‫بيئة‬ ‫سالمة‬  ‫االمن‬  ‫المخلفات‬ ‫و‬ ‫الخطرة‬ ‫المواد‬  ‫الدخان‬ ‫و‬ ‫الحريق‬ ‫من‬ ‫االمان‬  ‫الطبية‬ ‫االجهزة‬  ‫نظم‬ ‫المرافق‬ 25-Sep-22 11
 ‫االهداف‬ ‫اوال‬ Objectives  ‫تحقيقها‬ ‫الي‬ ‫نسعى‬ ‫التي‬ ‫النهائية‬ ‫النتائج‬ ‫من‬ ‫مجموعة‬ ‫هي‬  SMART  S : Specific ‫محددة‬  M : Measurable ‫للقياس‬ ‫قابلة‬  A : Achievable ‫للتحقيق‬ ‫قابلة‬  R : Relevant  T : Timely ‫بوقت‬ ‫محددة‬ 25-Sep-22 12
 ‫االهداف‬ ‫اوال‬ Objectives  ‫خالل‬ ‫المدنية‬ ‫الحماية‬ ‫اعمال‬ ‫على‬ ‫العاملين‬ ‫جميع‬ ‫تدريب‬ ‫؟‬ ‫واقعى‬ ‫غير‬ ‫شهر‬ ‫؟‬ ‫للتحقيق‬ ‫قابل‬ ‫غير‬  ‫تدريب‬ 25 % ‫الحماية‬ ‫اعمال‬ ‫على‬ ‫العاملين‬ ‫جميع‬ ‫من‬ ‫عام‬ ‫خالل‬ ‫المدنية‬ 25-Sep-22 13
 ‫المجال‬ ‫ثانيا‬ scope  ‫؟؟؟‬ ‫ايه‬ ‫بعمل‬ WHAT  ‫؟؟؟؟‬ ‫لمين‬ WHO  ‫؟؟؟‬ ‫اين‬ WHERE  ‫؟؟؟‬ ‫متى‬ WHEN 25-Sep-22 14
 ‫المجال‬ ‫ثانيا‬ scope  ‫؟؟؟‬ ‫ايه‬ ‫بعمل‬ WHAT ‫الحريق‬ ‫اخطار‬ ‫جميع‬ ‫من‬ ‫تامين‬ ‫و‬ ‫حماية‬  ‫؟؟؟؟‬ ‫لمين‬ WHO ‫عاملين‬ ‫و‬ ‫زوار‬ ‫و‬ ‫مرضى‬ ‫من‬ ‫المتواجدين‬ ‫جميع‬  ‫؟؟؟‬ ‫اين‬ WHERE ‫االقسام‬ ‫جميع‬  ‫؟؟؟‬ ‫متى‬ WHEN 7 ‫ايام‬ 24 ‫ساعة‬ 25-Sep-22 15
 ‫المجال‬ ‫ثانيا‬ scope  ‫بانحاء‬ ‫المتواجدين‬ ‫جميع‬ ‫تامين‬ ‫و‬ ‫حماية‬ ‫المنشأة‬ ‫غير‬ ‫و‬ ‫الطبية‬ ‫االقسام‬ ‫جميع‬ ‫في‬ ‫الحريق‬ ‫اخطار‬ ‫من‬ ‫عاملين‬ ‫و‬ ‫زوار‬ ‫و‬ ‫مرضى‬ ‫من‬ ‫الطبية‬ 24 ‫ساعة‬ 7 ‫اسبوعيا‬ ‫ايام‬ 25-Sep-22 16
 ‫االداء‬ ‫مؤشرات‬ ‫ثالثا‬ ( ‫الفعالية‬ EFFECTIVNESS )  ‫من‬ ‫و‬ ‫فعاليتها‬ ‫مدى‬ ‫من‬ ‫للتاكد‬ ‫بالخطة‬ ‫الموضوعة‬ ‫االجراءات‬ ‫و‬ ‫االداء‬ ‫لمتابعة‬ ‫مؤشر‬ ‫سابقا‬ ‫الموضوعة‬ ‫االهداف‬ ‫تحقيق‬ ‫امكانية‬ 25-Sep-22 17
 ‫الفعالية‬ ‫ثالثا‬ EFFECTIVNESS  ‫المؤشر‬ ‫تحديد‬  ‫المؤشر‬ ‫حساب‬ ‫كيفية‬ ‫تحديد‬ ( ‫المعادلة‬ )  ‫البيانات‬ ‫تجميع‬ ‫كيفية‬ ‫تحديد‬ ( Data collection sheet )  ‫القياس‬ ‫معدل‬ ‫تحديد‬ ( ‫شهري‬ – ‫سنوي‬ ‫ربع‬ ) .......  ‫بها‬ ‫المسموح‬ ‫النسب‬ ‫تحديد‬ 25-Sep-22 18
 ‫الفعالية‬ ‫ثالثا‬ EFFECTIVNESS  ‫المدنية‬ ‫الحماية‬ ‫اعمال‬ ‫على‬ ‫المدربين‬ ‫العاملين‬ ‫نسبة‬ ‫المؤشر‬ ‫تحديد‬  ‫المؤشر‬ ‫حساب‬ ‫كيفية‬ ‫تحديد‬ ( ‫المعادلة‬ )  ‫البسط‬ : ‫تدريبهم‬ ‫تم‬ ‫الذين‬ ‫العاملين‬ ‫عدد‬ ‫اجمالي‬ X 100  ‫المقام‬ : ‫العاملين‬ ‫عدد‬ ‫اجمالي‬ ‫بالمنشأة‬  ‫البيانات‬ ‫تجميع‬ ‫كيفية‬ ‫تحديد‬ ( Data collection sheet )  ‫القياس‬ ‫معدل‬ ‫تحديد‬ : ‫شهري‬  ‫بها‬ ‫المسموح‬ ‫النسب‬ ‫تحديد‬ : ‫زيادة‬ 5 % ‫السابق‬ ‫الشهر‬ ‫عن‬ ‫االقل‬ ‫على‬ 25-Sep-22 19
 ‫االجراءات‬ ‫و‬ ‫الخطوات‬ ‫رابعا‬ ( STRATEGY & Methodology ) ‫؟؟؟؟‬ ‫كيف‬ HOW???  ‫االهداف‬ ‫تحقيق‬ ‫و‬ ‫للوصول‬ ‫تتم‬ ‫التي‬ ‫الخطوات‬ ‫جميع‬  ‫تفصيلية‬  ‫المسئول‬ ‫تحديد‬  ‫الزمني‬ ‫االطار‬ 25-Sep-22 20
 ‫اخرى‬ ‫متطلبات‬  ‫المخاطر‬ ‫تقييم‬ Risk Assessment  ‫التدريب‬ Training  ‫التجارب‬ Drills  ‫المسئول‬ Responsible  ‫النماذج‬ forms  ‫المراجع‬ References  ‫التعريفات‬ Definitions 25-Sep-22 21
22 25-Sep-22
 NSR.16 Fire and smoke safety plan addresses prevention, early detection, response, and safe evacuation in case of fire and/or other internal emergencies 25-Sep-22 23
a) An ongoing risk assessment b) Early detection of fire and smoke system c) Fire suppression system d) Maintenance testing, inspection schedule e) Safe, unobstructed fire exits f) Safe storage and handling of highly flammable materials g) Proper annual training h) Plan is evaluated annually 25-Sep-22 24
An ongoing risk assessment that shall have the following features:  Assesses compliance with Civil Defense regulations. fire and building codes  high-risk areas for example stores, fuel tanks, kitchens including hoods, generators, laundry, oxygen supply, medical gases rooms, electrical control panels, medical files room, garbage room, etc.  all occupants including patients, families, staff, visitors, suppliers, contractors and others.  evacuation for fire and non-fire emergencies, for example, dangerous gas leakage.  A special risk assessment is performed during renovation and construction. 25-Sep-22 25
 ‫المنشأة‬ ‫انحاء‬ ‫كل‬ ‫يغطى‬ ‫االنذار‬ ‫نظام‬ : .1 ‫يدوي‬ .2 ‫اتوماتيك‬  ‫الساعة‬ ‫مدار‬ ‫على‬ ‫متابعتها‬ ‫يتم‬ ‫معنونة‬ ‫مركزية‬ ‫لوحات‬  ‫ذلك‬ ‫توثيق‬ ‫و‬ ‫بالمنشأة‬ ‫االنذار‬ ‫نظم‬ ‫لجميع‬ ‫متابعة‬ ‫و‬ ‫صيانة‬ ‫و‬ ‫فحص‬ 25-Sep-22 26
 ‫الحريق‬ ‫شدة‬ ‫و‬ ‫لنوع‬ ‫المناسبة‬ ‫االطفاء‬ ‫نظم‬ : .1 ‫يدوي‬ ( ‫حريق‬ ‫طفايات‬ ) .2 ‫اتوماتيكية‬ ‫اطفاء‬ ‫نظم‬  ‫االطفاء‬ ‫وسائط‬ ‫انواع‬ : .1 ‫المياه‬ .2 ‫ثاني‬ ‫الكربون‬ ‫اكسيد‬ .3 ‫الجافة‬ ‫الكيماوية‬ ‫البودرة‬ .4 ‫الرغوي‬ ‫السائل‬ .5 ‫الرطب‬ ‫الكيماوي‬ ‫السائل‬  ‫ذلك‬ ‫توثيق‬ ‫و‬ ‫االطفاء‬ ‫اجهزة‬ ‫جميع‬ ‫صيانة‬ ‫و‬ ‫فحص‬ ‫و‬ ‫متابعة‬ 25-Sep-22 27
 Safe fire exits  Unobstructed fire exits  Clear signage to assembly areas  Emergency light in addition to other related signage like how to activate the fire alarm using a fire extinguisher and hose reel 25-Sep-22 28
 The healthcare facility should perform proper annual training and orientation of all staff : 1. RACE 2. PASS 3. Safely evacuate all occupants 4. Evacuation of high-risk patients 25-Sep-22 29
30 25-Sep-22
31 25-Sep-22  ‫اإلنقاذ‬ ( rescue ) : ‫والذين‬ ‫بالمكان‬ ‫الموجودين‬ ‫أو‬ ‫المرضى‬ ‫إنقاذ‬ ‫آمن‬ ‫مكان‬ ‫ألقرب‬ ‫وإيصالهم‬ ‫المساعدة‬ ‫يحتاجون‬ .  ‫اإلنذارات‬ ‫تفعيل‬ ( activate ) : ‫يدوي‬ ‫إنذار‬ ‫جهاز‬ ‫أقرب‬ ‫تفعيل‬ ‫وا‬ ‫إلبالغ‬ ‫مكافحة‬ ‫فريق‬ ‫لمساعدة‬ ‫وذلك‬ ‫الحريق‬ ‫بمكان‬ ‫والتعريف‬ ‫الحدث‬ ‫عن‬ ‫السريع‬ ‫والتدخل‬ ‫الوصول‬ ‫في‬ ‫الحريق‬ .  ‫اإلنتشار‬ ‫تقليل‬ ( confine ) : ‫بغلق‬ ‫انتشارها‬ ‫ومنع‬ ‫النيران‬ ‫احتواء‬ ‫النيران‬ ‫تأجيج‬ ‫من‬ ‫األكسجين‬ ‫لمنع‬ ‫النوافذ‬ .  ‫اإلطفاء‬ ( extınguish ) ‫اإلخالء‬ ‫و‬ ( evacuate ) : ‫الطفاية‬ ‫استخدام‬ ‫المكان‬ ‫إخالء‬ ‫أو‬ ‫الحريق‬ ‫نوع‬ ‫ضوء‬ ‫في‬ ‫المناسبة‬ .
 The fire and smoke safety plan is evaluated annually and, whenever indicated, with aggregation and analysis of necessary data.  Key performance indicators (KPI) 25-Sep-22 32
33 25-Sep-22  NSR.16 (i) Fire drills are performed in different areas.
34 25-Sep-22 The healthcare facility shall record fire drills details including, but are not limited to, the following:  a) Dates and timings.  b) Staff who participated in the drill.  c) Involved areas.  d) Shifts.  e) Drill evaluation and corrective action plan.
35 25-Sep-22
NSR.17 The healthcare facility plans safe handling, storage, usage and transportation of hazardous materials and waste disposal. 36 25-Sep-22
Hazardous materials :  Chemical substances, which, if released or misused, can pose a threat to the environment, life or health. Industry, agriculture, medicine, research, and consumer goods use these chemicals. 37 25-Sep-22
 Hazardous material and waste are categorized into the following categories according to the WHO classification: o Infectious o Pharmaceutical o Chemical o Heavy metals o Pressurized containers o Sharps 38 25-Sep-22
a) A current and updated inventory of hazardous materials used in the healthcare facility b) Material safety data sheet (MSDS) should be available c) Appropriate labeling of hazardous materials. d) Procedure for safe usage, handling, storage, and spillage of hazardous materials e) Availability of required protective equipment and spill kits. 39 25-Sep-22
f) Investigation and documentation of different incidents g) Compliance with local laws and regulations, availability of required licenses, and/or permits. h) Staff training and orientation. i) The plan is evaluated and updated annually and/or when required. 40 25-Sep-22
Hazmatwaste inventory shall include :  Material name  Hazard type  Location  Usage  Consumption rate  Responsibility. 41 25-Sep-22
‫محتويات‬ MSDS ‫لكل‬ ‫مادة‬ • ‫المادة‬ ‫وصف‬ • ‫المرادفة‬ ‫االسماء‬ • ‫المادة‬ ‫خصائص‬ • ‫المحتملة‬ ‫االخطار‬ • ‫الطوارئ‬ ‫مجابهة‬ • ‫االولية‬ ‫االسعافات‬ • ‫التداول‬ • ‫التخزين‬ • ‫التخلص‬ ‫و‬ ‫المعالجة‬ • ‫الكيميائي‬ ‫التوافق‬ • ‫الثبات‬ ‫درجة‬ 42 25-Sep-22
43 25-Sep-22
44 25-Sep-22
 The healthcare facility develops and implements a document for spill management, Investigation, and recording of different incidents related to hazardous materials.  Spill kits available in all departments which content and size is suitable to type of spills that may occurs ( blood – chemical – flammable ……) 45 25-Sep-22
 Located with in the work area  High water flow shower  Gentle water flow for eye wash  Easy to operate (one move on/ off)  Continuous operation min. 15 minutes 46 25-Sep-22
 The plan is evaluated annually and, whenever indicated, with aggregation and analysis of necessary data.  Key performance indicators (KPI) 25-Sep-22 47
48 25-Sep-22
49 25-Sep-22
 ‫السالمة‬ : ◦ ‫للمرضى‬ ‫خطر‬ ‫أو‬ ‫تهديد‬ ‫واألجهزة‬ ‫الخالية‬ ‫المساحات‬ ‫و‬ ‫المباني‬ ‫تشكل‬ ‫مدى‬ ‫أي‬ ‫إلى‬ ‫والزوار‬ ‫والعاملين‬ ◦ ‫األمن‬ : ◦ ‫غير‬ ‫شيء‬ ‫استخدام‬ ‫أو‬ ‫مكان‬ ‫دخول‬ ‫أو‬ ،‫والعبث‬ ‫الدمار‬ ، ‫السرقة‬ ‫من‬ ‫الحماية‬ ‫به‬ ‫مصرح‬ 50 25-Sep-22
 NSR.18 A safe work environment plan addresses high-risk areas, procedures, risk mitigation requirements, tools, and responsibilities. 51 25-Sep-22
 The safety plan shall include at least the following: a) Proactive risk assessment. b) Effective planning to prevent accidents and injuries and minimize potential risks, to maintain safe conditions for all occupants to reduce and to control risks. c) Processes for pest and rodent control. 52 25-Sep-22
d) The healthcare facility identifies potential risks because of system failure and/or staff behavior, for example: 1. wet floor 2. water leakage from the ceiling beside electrical compartments 3. improper handling of sharps 4. non-compliance to personal protective equipment cutting and welding 5. dealing with high voltage 6. unsafe storage. 53 25-Sep-22
The safety plan shall include at least the following: e) Regular inspection with documentation of results, performing corrective actions, and appropriate follow up. f) Improvements for long-term upgrading or replacement. g) Safety training depending on job hazard analysis. 54 25-Sep-22
Safety instructions are posted in all high-risk areas : 1. Identifies risk and Prevention including PPE 2. Clear 3. Visible 25-Sep-22 55
 The pre-construction risk assessment includes, but is not limited to, the following: o Noise level o Vibration o Infection control o Air quality o Fire risk o Utilities affected (electricity, water, gases, etc.) o Hazardous materials o Waste and wreckage o Any other hazards related to construction/renovation  The healthcare facility ensures monitoring, documentation of all activities, and all risks related to construction and renovation. 25-Sep-22 56
 NSR.19 Security plan addresses security of all occupants and properties including restricted and isolated areas with risk mitigation, control measures, tools, and responsibilities. 25-Sep-22 57
 The security plan includes, but is not limited to, the following: a) Security risk assessment. b) Ensuring the identification of patients, visitors, and staff in the healthcare facility . c) Identification of vendors/contractors with the restriction of their movement within the healthcare facility . d) Vulnerable patients such as the elderly, infants, those with mental disorders, and handicapped should be protected from the abuse and above- mentioned harms. 25-Sep-22 58
 The security plan includes, but is not limited to, the following: e) Children should be protected from abduction. f) Drill for child abduction should be performed at least annually. g) Monitoring of remote and isolated areas. h) Staff training and orientation. i) The plan is evaluated annually and, if needed, according to related KPIs results or major incidents. 25-Sep-22 59
25-Sep-22 60
.1 ‫التجديد‬ ‫اعمال‬ ‫و‬ ‫االنشائية‬ ‫االعمال‬ ‫اثناء‬ ‫المواقع‬ ‫جميع‬ ‫تأمين‬ ‫و‬ ‫حماية‬ .2 ‫االمن‬ ‫و‬ ‫السالمة‬ ‫تعليمات‬ ‫بتنفيذ‬ ‫المستقلة‬ ‫الوحدات‬ ‫جميع‬ ‫التزام‬ ‫متابعة‬ .3 ‫المعزولة‬ ‫و‬ ‫البعيدة‬ ‫االماكن‬ ‫جميع‬ ‫متابعة‬ ‫و‬ ‫تحديد‬ : • ‫بها‬ ‫المستمر‬ ‫للتواجد‬ ‫امن‬ ‫افراد‬ ‫تعيين‬ • ‫المستمر‬ ‫المرور‬ • ‫المراقبة‬ ‫كاميرات‬ ‫طريق‬ ‫عن‬ ‫متابعتها‬ 61 25-Sep-22
.1 ‫االختطاف‬ ‫من‬ ‫والرضع‬ ‫األطفال‬ ‫حماية‬ .2 ‫حماية‬ ‫والزوار‬ ‫والعاملين‬ ‫المرضى‬ ‫االعتداء‬ ‫ذلك‬ ‫في‬ ‫بما‬ ‫ضرر‬ ‫اي‬ ‫من‬ .3 ‫جميع‬ ‫تمييز‬ ‫الموجودين‬ ‫بالم‬ ‫نشأة‬ ‫األوقات‬ ‫كافة‬ ‫في‬ : • ‫عاملين‬ • ‫مرضي‬ • ‫مترددين‬ ( ‫مندوبين‬ – ‫زوار‬ ) 4 . ‫المميزين‬ ‫غير‬ ‫األفراد‬ ‫عن‬ ‫التحرى‬ 62 25-Sep-22
63 25-Sep-22
64 25-Sep-22
• NSR.20 Medical equipment plan ensures safe selection, inspection, testing, maintenance, and safe use of medical equipment. 25-Sep-22 65
The plan shall address at least the following: a) Developing criteria for selecting new medical equipment. b) Inspection and testing of new medical equipment upon procurement and on a predefined interval basis. c) Training of staff on safe usage of medical equipment upon hiring upon installation of new equipment, and on a predefined regular basis by a qualified person. 25-Sep-22 66
d) Inventory of medical equipment including availability, criticality, and functionality. e) Identification of critical medical equipment that should be available for the operator even through provision of back-up such as life-saving equipment, ventilator, DC shock. f) Periodic preventive maintenance according to the manufacturer's recommendations which usually recommends using tagging systems by tagging dates and due dates of periodic preventive maintenance or labelling malfunctioned equipment. 25-Sep-22 67
The plan shall address at least the following: g) Calibration of medical equipment according to the manufacturer's recommendations and/or its usage. h) Malfunction and repair of medical equipment. i) Dealing with equipment adverse incidents, including actions taken, backup system, and reporting. j) Retiring of medical equipment. 25-Sep-22 68
 The healthcare facility shall have qualified individuals to oversee medical equipment management.  Staff are educated on the medical equipment plan at least annually  Critical medical equipment list is identified and back up availability is ensured. 25-Sep-22 69
Records are maintained for : 1. Medical equipment inventory 2. User training 3. Equipment identification cards 4. Company emergency contact 5. Testing on installation 6. Periodic preventive maintenance 7. Calibration 8. Malfunction history. 25-Sep-22 70
71 25-Sep-22
72 25-Sep-22
Some of the most important utilities include :  Mechanical (e.g., heating, ventilation and cooling)  Electrical (i.e., normal power and emergency power)  Domestic hot and cold water as well as other plumbing systems  Waste  Technology systems(myriad communications and data-transfer systems)  Vertical transportation utilities  Fuel systems  Access control  Surveillance systems  Medical gases, air and vacuum systems 73 25-Sep-22
a) Inventory of all utility key systems, for example, electricity, water supply, medical gases, heating, ventilation and air conditioning, communication systems, sewage, fuel sources, fire alarm, and elevators. b) Layout of the utility system. c) Staff training on utility plan. d) Regular inspection, testing, and corrective maintenance of utilities. 74 25-Sep-22
e) Testing of the electric generator with and without a load on a regular basis. f) Providing fuel required to operate the generator in case of an emergency. g) Cleaning and disinfecting of water tanks and testing of water quality with regular sampling for chemical and bacteriological examination with documentation of the results at least quarterly and/or more frequently if required by local laws and regulations or conditions of the source of water. 75 25-Sep-22
h) Preventive maintenance plan, according to the manufacturer's recommendations. i) The healthcare facility shall perform regular, accurate data aggregation, and analysis for example, frequency of failure, and preventive maintenance compliance for proper monitoring, updating, and improvement of the different systems. 76 25-Sep-22
 The healthcare facility has qualified staff members to oversee utility systems.  Staff are educated on the utility systems plan at least annually.  Records are maintained for utility systems inventory, testing, periodic preventive maintenance and malfunction history.  Critical utility systems are identified and back up availability is ensured. 77 25-Sep-22
78 25-Sep-22

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ES intro -PHCpptx.pdf that disricrib the

  • 3. • ‫هي‬ ‫الحيز‬ ‫الذى‬ ‫يعيش‬ ‫فيه‬ ‫اإلنسان‬ ‫و‬ ‫يمارس‬ ‫نشاطه‬ • ‫عرف‬ ‫القانون‬ ‫المصري‬ ‫البيئة‬ ‫بأنها‬ " ‫المحيط‬ ‫الحيوي‬ ‫الذي‬ ‫يشمل‬ ‫الكائنات‬ ‫الحية‬ ‫و‬ ‫ما‬ ‫يحويه‬ ‫من‬ ‫مواد‬ ‫و‬ ‫ما‬ ‫يحيط‬ ‫بها‬ ‫من‬ ‫هواء‬ ‫و‬ ‫ماء‬ ‫و‬ ،‫تربة‬ ‫و‬ ‫ما‬ ‫يقيمه‬ ‫اإلنسان‬ ‫من‬ ‫منشات‬ ‫فبذلك‬ ‫تشمل‬ ‫البيئة‬ ‫داخل‬ ‫المستشفي‬ ‫جميع‬ ‫االشخاص‬ ‫و‬ ‫المعدات‬ ‫و‬ ‫التجهيزات‬ ‫و‬ ‫االنشاءات‬ ‫وما‬ ‫يحيط‬ ‫بها‬ 25-Sep-22 3
  • 4. ‫المعدات‬ ‫و‬ ‫اآلالت‬ . ‫االنفجار‬ ‫و‬ ‫الحرائق‬ . ‫نقل‬ ‫وسائل‬ ‫المبنى‬ ‫طبيعة‬ ‫الحركة‬ ‫سامة‬ ‫معادن‬ . ‫أبخرة‬ ‫و‬ ‫غازات‬ . ‫و‬ ‫مذيبات‬ . ‫مبيدات‬ ‫حرارة‬ , ‫رطوبة‬ , ‫ضغط‬ , ‫اشعة‬ ‫األجر‬ . ‫اإلنسانية‬ ‫العالقات‬ . ‫الدعم‬ ‫األسرى‬ ‫و‬ ‫االجتماعي‬ ‫طفيليات‬ ‫و‬ ‫فيروسات‬ ‫و‬ ‫بكتريا‬ 25-Sep-22 4
  • 5.  ‫يجب‬ ‫الهدف‬ ‫لهذا‬ ‫نصل‬ ‫لكي‬ ‫إدارة‬ ‫الطبية‬ ‫والمعدات‬ ‫واألجهزة‬ ‫المرافق‬ ‫إلى‬ ‫تسعى‬ ‫فعالة‬ ‫بطريقة‬ : .1 ‫واإلصابات‬ ‫الحوادث‬ ‫وقوع‬ ‫منع‬ .2 ‫والمخاطر‬ ‫األخطار‬ ‫ومكافحة‬ ‫خفض‬ .3 ‫آمنة‬ ‫ظروف‬ ‫على‬ ‫الحفاظ‬ . 25-Sep-22 5
  • 6.  ‫المحلية‬ ‫اللوائح‬ ‫و‬ ‫للقوانين‬ ‫طبقا‬ ‫المهنية‬ ‫الصحة‬ ‫و‬ ‫السالمة‬ ‫أعمال‬ ‫تنظم‬ : .1 ‫قانون‬ 12 ‫لسنة‬ 2003 ( ‫الخامس‬ ‫الباب‬ ) .2 ‫قرار‬ 134 ‫لسنة‬ 2003 .3 ‫قرار‬ 211 ‫لسنة‬ 2003 .4 ‫قانون‬ 59 ‫لسنة‬ 1960 ( ‫المؤينة‬ ‫األشعة‬ . ) .5 ‫المصري‬ ‫الحريق‬ ‫كود‬ 25-Sep-22 6
  • 7.  Environmental and Facility Safety (EFS) in healthcare facilities aims at minimizing potential risks for patients, visitors, staff, and buildings through compliance with local laws, regulations, fire, and building codes for providing a safe and secure work environment. 25-Sep-22 7
  • 8.  ‫والمتابعة‬ ،‫والتدريب‬ ،‫التخطيط‬ ‫تشمل‬ ‫أن‬ ‫يجب‬ ‫الفعالة‬ ‫اإلدارة‬ : .1 ‫تخطيط‬ ‫الالزمة‬ ‫والموارد‬ ‫األجهزة‬ ‫و‬ ‫الخدمات‬ ‫و‬ ‫المرافق‬ ‫ادارة‬ ‫لكيفية‬ .2 ‫تدريب‬ ‫على‬ ‫العاملين‬ :  ‫اإلدارة‬ ‫خطط‬ ‫تطبيق‬  ‫المخاطر‬ ‫تقليل‬ ‫كيفية‬  ‫خطر‬ ‫تشكل‬ ‫التي‬ ‫األماكن‬ ‫عن‬ ‫تقرير‬ ‫وتقديم‬ ‫المتابعة‬ ‫كيفية‬ . .3 ‫المتابعة‬ ‫أولويات‬ ‫وتحديد‬ ‫األداء‬ ‫لتقييم‬ ‫معايير‬ ‫باستخدام‬ ‫التحسين‬ 25-Sep-22 8
  • 9. • Facility Management JCI • Environment & Facility Safety Egyptian ACC. • ISO 14000 family • Environmental management ISO • Occupational Health & Safety standards OSHA 25-Sep-22 9
  • 10. .1 ‫واألمن‬ ‫السالمة‬ Safety & Security .2 ‫والمخلفات‬ ‫الخطرة‬ ‫المواد‬ Hazardous Material & Waste .3 ‫الحرائق‬ ‫من‬ ‫األمان‬ Fire Safety .4 ‫الطبية‬ ‫األجهزة‬ Medical Equipment .5 ‫الخدمات‬ ‫و‬ ‫المرافق‬ ‫نظم‬ Utility Management .6 ‫المعمل‬ ‫في‬ ‫االمان‬ ‫برنامج‬ Laboratory Safety Prog .7 ‫االشعاعي‬ ‫االمان‬ ‫برنامج‬ Radiation Safety Prog 10 25-Sep-22
  • 11.  ‫خطة‬ ‫توجد‬ ............ ‫االداء‬ ‫ومؤشرات‬ ‫واالستراتيجية‬ ‫والمجال‬ ‫األهداف‬ ‫تشمل‬ :  ‫االشعاع‬ ‫من‬ ‫االمان‬  ‫المعمل‬ ‫في‬ ‫االمان‬  ‫العمل‬ ‫بيئة‬ ‫سالمة‬  ‫االمن‬  ‫المخلفات‬ ‫و‬ ‫الخطرة‬ ‫المواد‬  ‫الدخان‬ ‫و‬ ‫الحريق‬ ‫من‬ ‫االمان‬  ‫الطبية‬ ‫االجهزة‬  ‫نظم‬ ‫المرافق‬ 25-Sep-22 11
  • 12.  ‫االهداف‬ ‫اوال‬ Objectives  ‫تحقيقها‬ ‫الي‬ ‫نسعى‬ ‫التي‬ ‫النهائية‬ ‫النتائج‬ ‫من‬ ‫مجموعة‬ ‫هي‬  SMART  S : Specific ‫محددة‬  M : Measurable ‫للقياس‬ ‫قابلة‬  A : Achievable ‫للتحقيق‬ ‫قابلة‬  R : Relevant  T : Timely ‫بوقت‬ ‫محددة‬ 25-Sep-22 12
  • 13.  ‫االهداف‬ ‫اوال‬ Objectives  ‫خالل‬ ‫المدنية‬ ‫الحماية‬ ‫اعمال‬ ‫على‬ ‫العاملين‬ ‫جميع‬ ‫تدريب‬ ‫؟‬ ‫واقعى‬ ‫غير‬ ‫شهر‬ ‫؟‬ ‫للتحقيق‬ ‫قابل‬ ‫غير‬  ‫تدريب‬ 25 % ‫الحماية‬ ‫اعمال‬ ‫على‬ ‫العاملين‬ ‫جميع‬ ‫من‬ ‫عام‬ ‫خالل‬ ‫المدنية‬ 25-Sep-22 13
  • 14.  ‫المجال‬ ‫ثانيا‬ scope  ‫؟؟؟‬ ‫ايه‬ ‫بعمل‬ WHAT  ‫؟؟؟؟‬ ‫لمين‬ WHO  ‫؟؟؟‬ ‫اين‬ WHERE  ‫؟؟؟‬ ‫متى‬ WHEN 25-Sep-22 14
  • 15.  ‫المجال‬ ‫ثانيا‬ scope  ‫؟؟؟‬ ‫ايه‬ ‫بعمل‬ WHAT ‫الحريق‬ ‫اخطار‬ ‫جميع‬ ‫من‬ ‫تامين‬ ‫و‬ ‫حماية‬  ‫؟؟؟؟‬ ‫لمين‬ WHO ‫عاملين‬ ‫و‬ ‫زوار‬ ‫و‬ ‫مرضى‬ ‫من‬ ‫المتواجدين‬ ‫جميع‬  ‫؟؟؟‬ ‫اين‬ WHERE ‫االقسام‬ ‫جميع‬  ‫؟؟؟‬ ‫متى‬ WHEN 7 ‫ايام‬ 24 ‫ساعة‬ 25-Sep-22 15
  • 16.  ‫المجال‬ ‫ثانيا‬ scope  ‫بانحاء‬ ‫المتواجدين‬ ‫جميع‬ ‫تامين‬ ‫و‬ ‫حماية‬ ‫المنشأة‬ ‫غير‬ ‫و‬ ‫الطبية‬ ‫االقسام‬ ‫جميع‬ ‫في‬ ‫الحريق‬ ‫اخطار‬ ‫من‬ ‫عاملين‬ ‫و‬ ‫زوار‬ ‫و‬ ‫مرضى‬ ‫من‬ ‫الطبية‬ 24 ‫ساعة‬ 7 ‫اسبوعيا‬ ‫ايام‬ 25-Sep-22 16
  • 17.  ‫االداء‬ ‫مؤشرات‬ ‫ثالثا‬ ( ‫الفعالية‬ EFFECTIVNESS )  ‫من‬ ‫و‬ ‫فعاليتها‬ ‫مدى‬ ‫من‬ ‫للتاكد‬ ‫بالخطة‬ ‫الموضوعة‬ ‫االجراءات‬ ‫و‬ ‫االداء‬ ‫لمتابعة‬ ‫مؤشر‬ ‫سابقا‬ ‫الموضوعة‬ ‫االهداف‬ ‫تحقيق‬ ‫امكانية‬ 25-Sep-22 17
  • 18.  ‫الفعالية‬ ‫ثالثا‬ EFFECTIVNESS  ‫المؤشر‬ ‫تحديد‬  ‫المؤشر‬ ‫حساب‬ ‫كيفية‬ ‫تحديد‬ ( ‫المعادلة‬ )  ‫البيانات‬ ‫تجميع‬ ‫كيفية‬ ‫تحديد‬ ( Data collection sheet )  ‫القياس‬ ‫معدل‬ ‫تحديد‬ ( ‫شهري‬ – ‫سنوي‬ ‫ربع‬ ) .......  ‫بها‬ ‫المسموح‬ ‫النسب‬ ‫تحديد‬ 25-Sep-22 18
  • 19.  ‫الفعالية‬ ‫ثالثا‬ EFFECTIVNESS  ‫المدنية‬ ‫الحماية‬ ‫اعمال‬ ‫على‬ ‫المدربين‬ ‫العاملين‬ ‫نسبة‬ ‫المؤشر‬ ‫تحديد‬  ‫المؤشر‬ ‫حساب‬ ‫كيفية‬ ‫تحديد‬ ( ‫المعادلة‬ )  ‫البسط‬ : ‫تدريبهم‬ ‫تم‬ ‫الذين‬ ‫العاملين‬ ‫عدد‬ ‫اجمالي‬ X 100  ‫المقام‬ : ‫العاملين‬ ‫عدد‬ ‫اجمالي‬ ‫بالمنشأة‬  ‫البيانات‬ ‫تجميع‬ ‫كيفية‬ ‫تحديد‬ ( Data collection sheet )  ‫القياس‬ ‫معدل‬ ‫تحديد‬ : ‫شهري‬  ‫بها‬ ‫المسموح‬ ‫النسب‬ ‫تحديد‬ : ‫زيادة‬ 5 % ‫السابق‬ ‫الشهر‬ ‫عن‬ ‫االقل‬ ‫على‬ 25-Sep-22 19
  • 20.  ‫االجراءات‬ ‫و‬ ‫الخطوات‬ ‫رابعا‬ ( STRATEGY & Methodology ) ‫؟؟؟؟‬ ‫كيف‬ HOW???  ‫االهداف‬ ‫تحقيق‬ ‫و‬ ‫للوصول‬ ‫تتم‬ ‫التي‬ ‫الخطوات‬ ‫جميع‬  ‫تفصيلية‬  ‫المسئول‬ ‫تحديد‬  ‫الزمني‬ ‫االطار‬ 25-Sep-22 20
  • 21.  ‫اخرى‬ ‫متطلبات‬  ‫المخاطر‬ ‫تقييم‬ Risk Assessment  ‫التدريب‬ Training  ‫التجارب‬ Drills  ‫المسئول‬ Responsible  ‫النماذج‬ forms  ‫المراجع‬ References  ‫التعريفات‬ Definitions 25-Sep-22 21
  • 23.  NSR.16 Fire and smoke safety plan addresses prevention, early detection, response, and safe evacuation in case of fire and/or other internal emergencies 25-Sep-22 23
  • 24. a) An ongoing risk assessment b) Early detection of fire and smoke system c) Fire suppression system d) Maintenance testing, inspection schedule e) Safe, unobstructed fire exits f) Safe storage and handling of highly flammable materials g) Proper annual training h) Plan is evaluated annually 25-Sep-22 24
  • 25. An ongoing risk assessment that shall have the following features:  Assesses compliance with Civil Defense regulations. fire and building codes  high-risk areas for example stores, fuel tanks, kitchens including hoods, generators, laundry, oxygen supply, medical gases rooms, electrical control panels, medical files room, garbage room, etc.  all occupants including patients, families, staff, visitors, suppliers, contractors and others.  evacuation for fire and non-fire emergencies, for example, dangerous gas leakage.  A special risk assessment is performed during renovation and construction. 25-Sep-22 25
  • 26.  ‫المنشأة‬ ‫انحاء‬ ‫كل‬ ‫يغطى‬ ‫االنذار‬ ‫نظام‬ : .1 ‫يدوي‬ .2 ‫اتوماتيك‬  ‫الساعة‬ ‫مدار‬ ‫على‬ ‫متابعتها‬ ‫يتم‬ ‫معنونة‬ ‫مركزية‬ ‫لوحات‬  ‫ذلك‬ ‫توثيق‬ ‫و‬ ‫بالمنشأة‬ ‫االنذار‬ ‫نظم‬ ‫لجميع‬ ‫متابعة‬ ‫و‬ ‫صيانة‬ ‫و‬ ‫فحص‬ 25-Sep-22 26
  • 27.  ‫الحريق‬ ‫شدة‬ ‫و‬ ‫لنوع‬ ‫المناسبة‬ ‫االطفاء‬ ‫نظم‬ : .1 ‫يدوي‬ ( ‫حريق‬ ‫طفايات‬ ) .2 ‫اتوماتيكية‬ ‫اطفاء‬ ‫نظم‬  ‫االطفاء‬ ‫وسائط‬ ‫انواع‬ : .1 ‫المياه‬ .2 ‫ثاني‬ ‫الكربون‬ ‫اكسيد‬ .3 ‫الجافة‬ ‫الكيماوية‬ ‫البودرة‬ .4 ‫الرغوي‬ ‫السائل‬ .5 ‫الرطب‬ ‫الكيماوي‬ ‫السائل‬  ‫ذلك‬ ‫توثيق‬ ‫و‬ ‫االطفاء‬ ‫اجهزة‬ ‫جميع‬ ‫صيانة‬ ‫و‬ ‫فحص‬ ‫و‬ ‫متابعة‬ 25-Sep-22 27
  • 28.  Safe fire exits  Unobstructed fire exits  Clear signage to assembly areas  Emergency light in addition to other related signage like how to activate the fire alarm using a fire extinguisher and hose reel 25-Sep-22 28
  • 29.  The healthcare facility should perform proper annual training and orientation of all staff : 1. RACE 2. PASS 3. Safely evacuate all occupants 4. Evacuation of high-risk patients 25-Sep-22 29
  • 31. 31 25-Sep-22  ‫اإلنقاذ‬ ( rescue ) : ‫والذين‬ ‫بالمكان‬ ‫الموجودين‬ ‫أو‬ ‫المرضى‬ ‫إنقاذ‬ ‫آمن‬ ‫مكان‬ ‫ألقرب‬ ‫وإيصالهم‬ ‫المساعدة‬ ‫يحتاجون‬ .  ‫اإلنذارات‬ ‫تفعيل‬ ( activate ) : ‫يدوي‬ ‫إنذار‬ ‫جهاز‬ ‫أقرب‬ ‫تفعيل‬ ‫وا‬ ‫إلبالغ‬ ‫مكافحة‬ ‫فريق‬ ‫لمساعدة‬ ‫وذلك‬ ‫الحريق‬ ‫بمكان‬ ‫والتعريف‬ ‫الحدث‬ ‫عن‬ ‫السريع‬ ‫والتدخل‬ ‫الوصول‬ ‫في‬ ‫الحريق‬ .  ‫اإلنتشار‬ ‫تقليل‬ ( confine ) : ‫بغلق‬ ‫انتشارها‬ ‫ومنع‬ ‫النيران‬ ‫احتواء‬ ‫النيران‬ ‫تأجيج‬ ‫من‬ ‫األكسجين‬ ‫لمنع‬ ‫النوافذ‬ .  ‫اإلطفاء‬ ( extınguish ) ‫اإلخالء‬ ‫و‬ ( evacuate ) : ‫الطفاية‬ ‫استخدام‬ ‫المكان‬ ‫إخالء‬ ‫أو‬ ‫الحريق‬ ‫نوع‬ ‫ضوء‬ ‫في‬ ‫المناسبة‬ .
  • 32.  The fire and smoke safety plan is evaluated annually and, whenever indicated, with aggregation and analysis of necessary data.  Key performance indicators (KPI) 25-Sep-22 32
  • 33. 33 25-Sep-22  NSR.16 (i) Fire drills are performed in different areas.
  • 34. 34 25-Sep-22 The healthcare facility shall record fire drills details including, but are not limited to, the following:  a) Dates and timings.  b) Staff who participated in the drill.  c) Involved areas.  d) Shifts.  e) Drill evaluation and corrective action plan.
  • 36. NSR.17 The healthcare facility plans safe handling, storage, usage and transportation of hazardous materials and waste disposal. 36 25-Sep-22
  • 37. Hazardous materials :  Chemical substances, which, if released or misused, can pose a threat to the environment, life or health. Industry, agriculture, medicine, research, and consumer goods use these chemicals. 37 25-Sep-22
  • 38.  Hazardous material and waste are categorized into the following categories according to the WHO classification: o Infectious o Pharmaceutical o Chemical o Heavy metals o Pressurized containers o Sharps 38 25-Sep-22
  • 39. a) A current and updated inventory of hazardous materials used in the healthcare facility b) Material safety data sheet (MSDS) should be available c) Appropriate labeling of hazardous materials. d) Procedure for safe usage, handling, storage, and spillage of hazardous materials e) Availability of required protective equipment and spill kits. 39 25-Sep-22
  • 40. f) Investigation and documentation of different incidents g) Compliance with local laws and regulations, availability of required licenses, and/or permits. h) Staff training and orientation. i) The plan is evaluated and updated annually and/or when required. 40 25-Sep-22
  • 41. Hazmatwaste inventory shall include :  Material name  Hazard type  Location  Usage  Consumption rate  Responsibility. 41 25-Sep-22
  • 42. ‫محتويات‬ MSDS ‫لكل‬ ‫مادة‬ • ‫المادة‬ ‫وصف‬ • ‫المرادفة‬ ‫االسماء‬ • ‫المادة‬ ‫خصائص‬ • ‫المحتملة‬ ‫االخطار‬ • ‫الطوارئ‬ ‫مجابهة‬ • ‫االولية‬ ‫االسعافات‬ • ‫التداول‬ • ‫التخزين‬ • ‫التخلص‬ ‫و‬ ‫المعالجة‬ • ‫الكيميائي‬ ‫التوافق‬ • ‫الثبات‬ ‫درجة‬ 42 25-Sep-22
  • 45.  The healthcare facility develops and implements a document for spill management, Investigation, and recording of different incidents related to hazardous materials.  Spill kits available in all departments which content and size is suitable to type of spills that may occurs ( blood – chemical – flammable ……) 45 25-Sep-22
  • 46.  Located with in the work area  High water flow shower  Gentle water flow for eye wash  Easy to operate (one move on/ off)  Continuous operation min. 15 minutes 46 25-Sep-22
  • 47.  The plan is evaluated annually and, whenever indicated, with aggregation and analysis of necessary data.  Key performance indicators (KPI) 25-Sep-22 47
  • 50.  ‫السالمة‬ : ◦ ‫للمرضى‬ ‫خطر‬ ‫أو‬ ‫تهديد‬ ‫واألجهزة‬ ‫الخالية‬ ‫المساحات‬ ‫و‬ ‫المباني‬ ‫تشكل‬ ‫مدى‬ ‫أي‬ ‫إلى‬ ‫والزوار‬ ‫والعاملين‬ ◦ ‫األمن‬ : ◦ ‫غير‬ ‫شيء‬ ‫استخدام‬ ‫أو‬ ‫مكان‬ ‫دخول‬ ‫أو‬ ،‫والعبث‬ ‫الدمار‬ ، ‫السرقة‬ ‫من‬ ‫الحماية‬ ‫به‬ ‫مصرح‬ 50 25-Sep-22
  • 51.  NSR.18 A safe work environment plan addresses high-risk areas, procedures, risk mitigation requirements, tools, and responsibilities. 51 25-Sep-22
  • 52.  The safety plan shall include at least the following: a) Proactive risk assessment. b) Effective planning to prevent accidents and injuries and minimize potential risks, to maintain safe conditions for all occupants to reduce and to control risks. c) Processes for pest and rodent control. 52 25-Sep-22
  • 53. d) The healthcare facility identifies potential risks because of system failure and/or staff behavior, for example: 1. wet floor 2. water leakage from the ceiling beside electrical compartments 3. improper handling of sharps 4. non-compliance to personal protective equipment cutting and welding 5. dealing with high voltage 6. unsafe storage. 53 25-Sep-22
  • 54. The safety plan shall include at least the following: e) Regular inspection with documentation of results, performing corrective actions, and appropriate follow up. f) Improvements for long-term upgrading or replacement. g) Safety training depending on job hazard analysis. 54 25-Sep-22
  • 55. Safety instructions are posted in all high-risk areas : 1. Identifies risk and Prevention including PPE 2. Clear 3. Visible 25-Sep-22 55
  • 56.  The pre-construction risk assessment includes, but is not limited to, the following: o Noise level o Vibration o Infection control o Air quality o Fire risk o Utilities affected (electricity, water, gases, etc.) o Hazardous materials o Waste and wreckage o Any other hazards related to construction/renovation  The healthcare facility ensures monitoring, documentation of all activities, and all risks related to construction and renovation. 25-Sep-22 56
  • 57.  NSR.19 Security plan addresses security of all occupants and properties including restricted and isolated areas with risk mitigation, control measures, tools, and responsibilities. 25-Sep-22 57
  • 58.  The security plan includes, but is not limited to, the following: a) Security risk assessment. b) Ensuring the identification of patients, visitors, and staff in the healthcare facility . c) Identification of vendors/contractors with the restriction of their movement within the healthcare facility . d) Vulnerable patients such as the elderly, infants, those with mental disorders, and handicapped should be protected from the abuse and above- mentioned harms. 25-Sep-22 58
  • 59.  The security plan includes, but is not limited to, the following: e) Children should be protected from abduction. f) Drill for child abduction should be performed at least annually. g) Monitoring of remote and isolated areas. h) Staff training and orientation. i) The plan is evaluated annually and, if needed, according to related KPIs results or major incidents. 25-Sep-22 59
  • 61. .1 ‫التجديد‬ ‫اعمال‬ ‫و‬ ‫االنشائية‬ ‫االعمال‬ ‫اثناء‬ ‫المواقع‬ ‫جميع‬ ‫تأمين‬ ‫و‬ ‫حماية‬ .2 ‫االمن‬ ‫و‬ ‫السالمة‬ ‫تعليمات‬ ‫بتنفيذ‬ ‫المستقلة‬ ‫الوحدات‬ ‫جميع‬ ‫التزام‬ ‫متابعة‬ .3 ‫المعزولة‬ ‫و‬ ‫البعيدة‬ ‫االماكن‬ ‫جميع‬ ‫متابعة‬ ‫و‬ ‫تحديد‬ : • ‫بها‬ ‫المستمر‬ ‫للتواجد‬ ‫امن‬ ‫افراد‬ ‫تعيين‬ • ‫المستمر‬ ‫المرور‬ • ‫المراقبة‬ ‫كاميرات‬ ‫طريق‬ ‫عن‬ ‫متابعتها‬ 61 25-Sep-22
  • 62. .1 ‫االختطاف‬ ‫من‬ ‫والرضع‬ ‫األطفال‬ ‫حماية‬ .2 ‫حماية‬ ‫والزوار‬ ‫والعاملين‬ ‫المرضى‬ ‫االعتداء‬ ‫ذلك‬ ‫في‬ ‫بما‬ ‫ضرر‬ ‫اي‬ ‫من‬ .3 ‫جميع‬ ‫تمييز‬ ‫الموجودين‬ ‫بالم‬ ‫نشأة‬ ‫األوقات‬ ‫كافة‬ ‫في‬ : • ‫عاملين‬ • ‫مرضي‬ • ‫مترددين‬ ( ‫مندوبين‬ – ‫زوار‬ ) 4 . ‫المميزين‬ ‫غير‬ ‫األفراد‬ ‫عن‬ ‫التحرى‬ 62 25-Sep-22
  • 65. • NSR.20 Medical equipment plan ensures safe selection, inspection, testing, maintenance, and safe use of medical equipment. 25-Sep-22 65
  • 66. The plan shall address at least the following: a) Developing criteria for selecting new medical equipment. b) Inspection and testing of new medical equipment upon procurement and on a predefined interval basis. c) Training of staff on safe usage of medical equipment upon hiring upon installation of new equipment, and on a predefined regular basis by a qualified person. 25-Sep-22 66
  • 67. d) Inventory of medical equipment including availability, criticality, and functionality. e) Identification of critical medical equipment that should be available for the operator even through provision of back-up such as life-saving equipment, ventilator, DC shock. f) Periodic preventive maintenance according to the manufacturer's recommendations which usually recommends using tagging systems by tagging dates and due dates of periodic preventive maintenance or labelling malfunctioned equipment. 25-Sep-22 67
  • 68. The plan shall address at least the following: g) Calibration of medical equipment according to the manufacturer's recommendations and/or its usage. h) Malfunction and repair of medical equipment. i) Dealing with equipment adverse incidents, including actions taken, backup system, and reporting. j) Retiring of medical equipment. 25-Sep-22 68
  • 69.  The healthcare facility shall have qualified individuals to oversee medical equipment management.  Staff are educated on the medical equipment plan at least annually  Critical medical equipment list is identified and back up availability is ensured. 25-Sep-22 69
  • 70. Records are maintained for : 1. Medical equipment inventory 2. User training 3. Equipment identification cards 4. Company emergency contact 5. Testing on installation 6. Periodic preventive maintenance 7. Calibration 8. Malfunction history. 25-Sep-22 70
  • 73. Some of the most important utilities include :  Mechanical (e.g., heating, ventilation and cooling)  Electrical (i.e., normal power and emergency power)  Domestic hot and cold water as well as other plumbing systems  Waste  Technology systems(myriad communications and data-transfer systems)  Vertical transportation utilities  Fuel systems  Access control  Surveillance systems  Medical gases, air and vacuum systems 73 25-Sep-22
  • 74. a) Inventory of all utility key systems, for example, electricity, water supply, medical gases, heating, ventilation and air conditioning, communication systems, sewage, fuel sources, fire alarm, and elevators. b) Layout of the utility system. c) Staff training on utility plan. d) Regular inspection, testing, and corrective maintenance of utilities. 74 25-Sep-22
  • 75. e) Testing of the electric generator with and without a load on a regular basis. f) Providing fuel required to operate the generator in case of an emergency. g) Cleaning and disinfecting of water tanks and testing of water quality with regular sampling for chemical and bacteriological examination with documentation of the results at least quarterly and/or more frequently if required by local laws and regulations or conditions of the source of water. 75 25-Sep-22
  • 76. h) Preventive maintenance plan, according to the manufacturer's recommendations. i) The healthcare facility shall perform regular, accurate data aggregation, and analysis for example, frequency of failure, and preventive maintenance compliance for proper monitoring, updating, and improvement of the different systems. 76 25-Sep-22
  • 77.  The healthcare facility has qualified staff members to oversee utility systems.  Staff are educated on the utility systems plan at least annually.  Records are maintained for utility systems inventory, testing, periodic preventive maintenance and malfunction history.  Critical utility systems are identified and back up availability is ensured. 77 25-Sep-22