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UTILITY SYSTEMS MANAGEMENT PLAN 2008 1. GOALS 2. OBJECTIVES 3. SCOPE 4. RESPONSIBILITIES 5. UTILITY SYSTEMS MANAGEMENT PROCESSES a. Design and Installation of the Utility Systems b. Risk Criteria, Inventory and Strategies c. Inspecting, Testing and Maintenance Strategies d. Inspecting, Testing and Maintenance Intervals e. Emergency Procedures f. Mapping the Distribution of Utility Systems g. Labeling for Emergency Shutdown h. Pathogenic Biological Agents in Cooling Towers and Water Systems i. Pressure Relationships, Air Exchange Rates, and Filtration Efficiencies j. Emergency Electrical Power Systems k. Maintaining Documentation l. Maintaining the Emergency Electrical Power Systems m. Piped Medical Gas Systems n. Incident Reporting and Investigation o. Monitoring of Performance p. Annual Evaluation q.
Orientation and Education Program 1. GOALS. To
provide an environment of care (EC) that is safe, controlled, and comfortable;
reduce the potential for nosocomial illness; minimize the risks associated with
utility failures; and to ensure the operational reliability of utility systems.
These goals are consistent with the Command’s mission in providing quality
healthcare to soldiers, retirees, and their families.
2. OBJECTIVES. This plan is designed to protect people, equipment, property,
and the environment by ensuring the safe and reliable operation of the utility
systems that impact life support, infection control, environmental support,
equipment support, and communications. The primary objectives of this plan
are: a. Ensuring
compliance with applicable regulatory requirements, standards and guidelines,
and manufacturers’ recommendations. b. Carrying out
an effective preventive maintenance program. c. Providing
operator and user training.
d. Maintaining reference documents for each system.
e. Establishing effective contingency plans in the event of a utility
system failure.
f. Monitoring equipment performance and identifying improvement
opportunities.
g. Maintaining required permits and licenses. 3. SCOPE. a. The plan
applies to this Military Treatment Facility (MTF) and all subordinate MTFs to
include (LIST CLINICS AND SATELLITE LOCATIONS SERVED BY THE FACILITY). b. The
utility systems covered under this plan are: electrical distribution; emergency
power; horizontal and vertical transport (elevators and pneumatic tube system);
heating, ventilating, and air conditioning; plumbing; boiler and steam; medical
gases; medical/surgical vacuum; and facility communication systems (nurse call,
overhead paging, computer, and telephone). 4. RESPONSIBILITES. a. The
Facility Manager is responsible for developing, implementing, and monitoring
this plan and ensures that required inspections, tests, and maintenance of the
utility systems except for the communication systems are completed as
required. b. The
Chief, Information Management is responsible for inspections, tests,
and maintenance of the communication systems. c. The
(INSTALLATION) Department of Public Works inspects, tests, and maintains the
(LIST) systems. d. The
(CONTRACTOR NAME) inspects, tests, and maintains the (LIST) systems. e. The
organization chart in Appendix A shows the primary officers, departments, and
services that provide input into the development and implementation,
and maintenance of the Utility ManagementProgram. f. All staff
must be trained and competent in safe operation and use of utility systems and
in emergency response and reporting procedures. 5. UTILITY
SYSTEMS MANAGEMENT PROCESSES. This management plan is based on a plan, teach,
implement, respond, monitor, and improve cycle. Appendix B lists the
corresponding policies, regulations, SOPs, systems, and databases pertaining to
each of these requirements. a. Design and
Installation of Utility Systems. The Facility Manager uses the Department of
Defense Medical Military Construction Program Facilities Design and Construction
Criteria, MIL-HDBK-1191 July 09, 2002 and AIA Guidelines for Design and
Construction of Hospital and Healthcare Facilities, 2001 ED as references to
make sure that the utility systems meet the patient care and operational needs
of the services in the MTF’s buildings. b. Risk
Criteria, Inventory and Strategies. All utility systems having an impact on the
environment, life support, infection control, support of the environment,
equipment, and communications are classified as critical systems. The
Facilities Department utilizes the Defense Medical Logistics Standard Support (DMLSS)
System to maintain a current, accurate inventory of the utility systems and
their critical operating components covered under this plan. Newly acquired
equipment is added to the inventory within three months of
acquisition/installation. c.
Inspecting, Testing, and Maintenance Strategies.
(1) Operational plans provide guidance for the management and
implementation of the Utility Program, including maintenance, testing, and
inspection procedures to support operational reliability, managing risks in the
EC, and training system operator and users. These documents are summarized in
Table 7.1.
(2) The Facilities Department maintains written procedures that
include performance standards for inspecting, testing, and maintaining critical
operating components of utility systems in accordance with applicable
regulations, standards, guidelines and manufacturers’ recommendations, risk
levels and current MTF experience. These documents are summarized in Table
7.2.
(3) All systems or components included in
the Preventive Maintenance Program (PMP) are assigned a unique identification
number and a corresponding record is created in the DMLSS database. The
identification numbers attach each component to a
specific preventive maintenance procedure, schedule and service history
file. (4) The
MTF maintains documentation in the DMLSS database for the following – (a)
A current, accurate, and separate inventory of utility components included in
the utility management plan.
(b) Performance and safety testing of each critical component
identified in the plan before initial use.
(c) Critical components of life support utility
systems/equipment consistent with maintenance strategies.
(d) Critical components of infection control utility
systems/equipment for high-risk patients.
(e) Critical components of non-life support utility
systems/equipment.
d. Inspecting, Testing, and Maintenance Intervals.
(1) The PMP facilitates program implementation and time management,
and it serves as a tracking tool to ensure that required inspections, tests,
and maintenance, are performed, completed in a timely manner, and properly
documented.
(2) All systems are tested prior to initial use and annually unless
otherwise specified by pertinent regulations, standards and guidelines, and
manufacturer’s recommendations, or by equipment needs based on performance
history or risks. The latter is determined by the Facility Manager through
evaluation of all repairs and preventive maintenance to each system
component.
(3) The Facilities Department’s Quality Control Manager randomly
selects about 3% of the equipment having undergone preventive maintenance,
inspects the chosen equipment, and compares his findings with those of the
operator who originally inspected the equipment. Appropriate action is taken
whenever discrepancies occur. e. Emergency Procedures. Emergency procedures for Utility Systems Management are maintained in policies and procedures maintained by Facilities Department; Plans, Training, Mobilization, and Security (PTMS); and the Department of Nursing. These emergency procedures address the following –
(1)
Specific procedures in the event of utility systems malfunction (2)
Identification of an alternate source of essential utilities (3)
Shutoff of malfunctioning systems and notification of staff in affected areas (4)
Procedures for obtaining repair services when utility systems fail f. Mapping
the Distribution of Utility Systems. For each major system, the Facilities
Department maintains current, detailed schematics mapping the layout of each
system. These schematics show technical details and operational procedures.
These documents also include distribution and controls for partial or complete
shutdown as well as operating procedures for key controls to include
notification of staff in affected areas. g. Labeling
for Emergency Shutdown. The Facilities Department labels controls for a partial
or complete emergency shutdown. Emergency shutoff controls are inspected
annually. h.
Pathogenic Biological Agents in Cooling Towers and Water Systems.
(1) The key steps for managing pathogenic biological agents in
aerosolizing water systems are to ensure that equipment that re-circulates water
continuously is properly designed, accurately installed, and adequately
maintained.
(2) Guidance followed for controlling pathogenic biological agents
in aerosolizing water systems are listed in Appendix D. (3) If there is a case of suspected or known nosocomial infection, the Facility Manager works together with the Infection Control and Preventive Medicine to review engineering policies and procedures related to inspections, preventive maintenance, and the culturing guidelines to be used.
i.
Pressure Relationships, Air Exchange Rates, and Filtration Efficiencies.
(1) The key steps for managing airborne contaminants are the correct
design, installation and maintenance of air handling and ventilation systems.
Emphasis is placed on the proper pressure relationships, air exchange rates, and
filtration efficiencies in areas where patients are treated or housed that may
have auto immune systems that are suppressed. These areas include operating
rooms, special procedure rooms, delivery rooms, protective isolation rooms,
laboratories and sterile supply rooms.
(2) Guidance followed for controlling airborne contaminants are
listed in Appendix D. (3) If
there is a case of suspected or known nosocomial infection, the Facility Manager
works together with Infection Control and Preventive Medicine to review
engineering policies and procedures related to
inspections, preventive maintenance, and the culturing guidelines to be used. j. Emergency
Electrical Power Systems. The Facilities Management Branch conducts testing of
the emergency power system at least every 30 days using the current edition of
NFPA 00 and NFPA 110. When normal power is interrupted, the emergency power
source supplies electricity to the following: (1) Alarm
systems (2) Exit
route illumination (3) Emergency communication systems
(4) Illumination of exit signs
(5)
Blood, bone, and tissue storage units (6) N/A (7) Emergency/urgent care areas
(8) Elevators (at least one for nonambulatory patients)
(9) Medical air compressors
(10) Medical and surgical vacuum systems
(11) Areas where electrically powered life-support equipment is used
(12) N/A
(13)
N/A (14)
Operating rooms (15)
Postoperative recovery rooms (16)
Obstetrical delivery rooms (17)
Newborn nurseries
k. Maintaining Documentation. Through DMLSS, the hospital maintains
documentation for the following:
l. Maintaining the Emergency Electrical Power Systems.
(2) Generator testing is conducted 12 times a year, with interval
not less than 20 days and not more then 40 days apart. Testing is conducted for
at least 30 continuous minutes under a dynamic load that is at least 30% of the
nameplate rating of the generator. Generators that are tested to less than the
30% of the nameplate rating still require a 30 minute testing period. Guidance
for testing generators that tested less than the nameplate rating and for
diesel-powered generators that do not meet the minimum exhaust gas temperatures
is located in the JC EC Standard EC.7.40.
(3) All transfer switches are tested 12 times annually with the
testing intervals not less than 20 days and not more than 40 days apart.
(4) Battery-powered lights for egress purposes are tested for 30
seconds every 30 days, and for 1½ hours annually.
(6)
Facilities Management Branch further tests each emergency generator at least
once every 36 months for a minimum of four continuous hours. The test is
conducted under a load (dynamic or static as necessary) that is at least 30 %
of the nameplate rating of the generator. (7) If a
test fails, the Facilities Management Branch implements interim measures to
compensate for the risk to patients, visitors, and staff until necessary
repairs or corrections are completed. (8) If a
test fails, the organization performs a retest after making the necessary
repairs or corrections. m. Piped
Medical Gas Systems.
(1) The medical gas system includes compressed air for medical and
dental patient and laboratory use; vacuum for medical and dental patient use,
laboratory dust collection, and waste anesthesia gas disposal; and gases for
patient, laboratory, and equipment use. The system design includes centralized
gas storage, compressors, a piped distribution system, and connection outlets.
Point-of-use or decentralized systems are also included.
(2) The medical gas system is installed and tested in accordance
with NFPA 99. Testing includes, but is not limited to, cross-connection,
purity, pressure, and alarm testing. All testing and certification of the
medical gas systems is done by an independent testing agency. n.
Incident Reporting and Investigation.
(1) The Facility Manager identifies, documents, investigates, and
evaluates utility system incidents, failures, problems, or user errors to
identify trends and problems that pose a potential threat to health and safety
and opportunities for improvement. Investigations may include a review of
equipment service reports, incident reports, utility failures, and user errors.
Corrective actions are implemented in a timely manner and the results are
evaluated for effectiveness.
(2) Typical incidents that require reporting and investigation
include normal electric power system failures, emergency power system failures,
water system failures or contamination, steam system failures, sewer system
leaks and major blockages, medical gas system failures, disruption of HVAC
service to patient care units and service areas, and any other incident deemed
appropriate by the Facility Manager. o.
Monitoring of Performance.
(1) Performance monitoring is used to –
(a) Identify areas of concern and strengths in the MTF’s
Safety Program.
(b) Identify or determine actions necessary to address areas
of concern.
(c) Assess actual compliance with relevant security
standards.
(2) The Facility Manager –
(a) Identifies at least one measurable performance improvement
standard to monitor performance regarding actual or potential risk related to
one or more of the following –
(1) Staff knowledge and skills
(2) Level of staff participation
(3) Monitoring and inspection activities
(4) Emergency and incident reporting
(5) Inspection, preventive maintenance, and testing of
equipment
(b) Considers high-risk, high-volume or chronic problems when
developing performance standards to better focus limited resources.
(c) Sets desired goals or benchmarks and develops and
implements data collection and reporting procedures.
(3) The EC Committee tracks performance and documents the results in
the committee minutes. (4)
Annually, the EC Committee recommends at least one EC performance improvement
standard to the Executive Committee for review and inclusion in the MTF’s
performance improvement program.
(5) The current performance standard(s) is listed in Table 7.3.
p. Annual
Evaluation. (1) The
Facility Manager evaluates the management plan and presents the evaluation to
the EC Committee for review and approval each January. In performing the annual
review, the he uses a variety of sources such as inspection and audit results,
accident/incident reports, employee reports of unsafe or unhealthy working
conditions, customer satisfaction surveys, suggestion boxes, performance
improvement committees, and other statistical information and tracking reports.
The Facility Manager may also use other forms of review and input from relevant
sources such as leadership, other EC disciplines, management, staff, personnel,
and volunteers. (2) The
annual evaluation includes an assessment of the plan’s – (a)
Scope. Based on the outcome of objectives assessment, the scope of the plan is
expanded, reduced or maintained at its present scope (buildings, equipment,
people, operations, services)
(b) Objectives. An annual assessment is made to determine if
the objectives, as outlined in paragraphs 2.a through 2.g were met
(c) Performance. Review of performance standard(s) is made
to determine the level of performance and whether the level of performance is
acceptable
(d) Effectiveness. An acceptable level of effectiveness is
determined by attaining success in meeting objectives and producing a
satisfactory level of performance
(3) Once the EC Committee approves the annual review, the results
are submitted to the Executive Committee for review and approval.
(4) The annual review is used as an opportunity to develop or modify
programs, plans, and policies; identify and implement additional or more
effective controls; and enhance the Employee Orientation and Annual Refresher
Training Programs.
q. Orientation and Education Program. (1) The
orientation and education component pertaining to safety addresses the
following criteria –
(a) The utility system's capabilities, limitations, and
special applications.
(b) Emergency procedures in the event of system failure.
(c) Certification, license or information and skills necessary
to perform assigned maintenance responsibilities.
(d) Location and instructions for use of emergency shutoff
controls.
(e) Processes for reporting utility
system management problems, failures, and user errors.
(2) The Chief, Plans, Training, Mobilization, and Security (PTMS)
Office manages the organization-wide New Employee Orientation Program.
Generally, new employees are scheduled to attend orientation within 30 days of
hire.
(3) The Chief, PTMS Office manages the Annual Refresher Training
Program. Generally, all staff and personnel attend annual refresher training
during their birth month.
(4) Supervisors provide worksite-specific orientation and annual
refresher training.
(5) All training is documented in the staff competency folders. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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