MHHS
ENVIRONMENT OF CARE/ENGINEERING POLICY AND PROCEDURE MANUAL
TITLE: Utilities Management Plan
CATEGORY: Engineering Services
INDEX NUMBER: UM 701
ORIGINAL DATE: June 2004
LAST REVIEW DATE: June 2004
SUPERSEDES:
1.PURPOSE
1.1 TheUtilities Management Program at a Memorial HermannHospital System facility involves a coordinated effort of the Environment of Care (EC) Committee, Facilities Engineering and other departments within the hospital. Together, they strive to provide a safe environment for all patients, visitors and staff by ensuring the operational reliability and safety of the facilities essential utility systems. This Plan provides a framework to guide the actions of the hospital leadership and staff in the event of failures or other situation that impacts the operations of hospital utilities. By definition, Utility Systems include organization’s systems for life support, surveillance, prevention, and control of infection, environmental support; and equipment support. In addition, utility systems may include electrical distribution; emergency power; vertical and horizontal transport; heating, ventilation, and air conditioning (HVAC); plumbing, steam; piped gases; vacuum systems; and communication systems including data exchange systems.
2.INTENT
2.1 It is the intent of a Memorial Hermann Hospital System facility to prepare, implement and continuously evaluate a Utility Management plan to ensure the safety, security, quality and reliability of utility service to patients, staff, and visitors in accordance with all applicable standards of the Joint Commission for Accreditation of Healthcare Organizations, and other applicable codes and regulations.
3.SCOPE
3.1 The Utility Systems Management Program is designed to assure design, installation and maintenance of appropriate utility systems equipment to support the Patient Care mission of the facility. The program is also designed to assure effective preparation of staff responsible for the use or maintenance and repair of the equipment. Finally, the program is designed to assure continual availability of a comfortable, safe, and effective patient care environment through a program of planned maintenance, timely repair, and evaluation of all events that could have an adverse impact on the safety of patients or staff. Outcomes of this program ensure the reliability of utility systems, reduces the potential for hospital-acquired illness to be transmitted through utility systems, and assesses the reliability while minimizing potential risks of utility system failures.
4.FUNDAMENTALS
4.1 The complexity of utility systems required to support complex patient care continues to increase. Selecting new or upgraded utility system technology requires research and a team approach to assure all functional and medical needs are met. MemorialHermannHospital System implements a process where utility system specifications for renovations and new construction are evaluated by in-house and external professionals. These specifications are evaluated for reliability, service requirements, maintenance, and emergency support. They are published as a design document template and are available on-line.
4.2 Patient care providers need training to understand how utility systems support patient care, limitations of system performance, safe operating conditions, safe work practices, and emergency clinical interventions during interruptions.
4.3 Critical components of utility systems require maintenance to minimize the potential for failures.
4.4 Emergency response procedures are required to manage utility system failures or service disruptions.
5.OBJECTIVES
5.1 The management plan describes the processes used to assure that the utility systems are designed and maintained to assure a safe and effective Environment of Care. Outcomes of the program, significant deviations from the standards and processes are reviewed/reportedquarterly to the respective EC Committee and further analyzed during the annual evaluation process.
5.2 An assessment of the risks and consequences of utility system failure is conducted whenever significant changes occur to the respective utility system or environment. Changes in identified risks are included in changes in the procedures, training, and/or equipment provided and are noted in year end EC Evaluations.
5.3 The criteria for selection of the appropriate maintenance strategy in the Utility Systems inventory are included in the assessment process.
5.4 The Preventive Maintenance (PM) program includes tests and inspections for each item or class of items in the PM elements of utility management program, and these are reviewed as equipment is changed or significant issues arise from the existing PM program. Required changes or substantial deviations are reported to the ECCommittee. An overview of program results, statistics, and utility failures/issues/errors are reported to the EC Committee on a quarterly basis.
5.5 Medical Gas System components are tested and inspected at least annually.
5.6 The process to test and certify Medical Gas System piping and systems is established, and is utilized following any invasive maintenance, construction, or renovation project as applicable.
5.7 The processes used to control pathogenic biological organisms in the cooling water, domestic water, and specialty patient care water systems are included in the PM program for utilities.
5.8 The processes used to control infection by maintenance of pressure relationships and air filtration are included in this program.
5.9 Operational plans for normal and urgent emergency operations of utility system elements are evaluated initially and/or when significant changes occur to the respective utility system.
5.10 The processes used to document, analyze and evaluate utility system problems/failures and errors is used to make reports to the ECCommittee quarterly, which are further summarized as part of the annual evaluation.
5.11 Performance is measured using an appropriate performance monitor, which is evaluated and reported to the ECCommittee quarterly, and evaluated for appropriateness at least annually, via the annual evaluation process
5.12 Emergency procedures for response to failure or malfunction of utility systems are evaluated and exercised periodically, and the results reported to the ECCommittee.
5.13 Emergency power systems are tested monthly, and preventive maintenance performed at least annually, as defined in governing standards. Summary information and significant issues are reported to the ECCommittee.
5.14 There is an annual evaluation of the scope, objectives, performance and effectiveness of the Utility Systems Program.
6.ORGANIZATION AND RESPONSIBILITY
6.1The Quality Committee and/or Governing Body receive reports of activities of the Utility Management Program from the ECCommittee. They review reports and, as appropriate, provide feedbackabout identified issues. They may also recommend (via the administrative budgeting process) capital budget expenses, as necessary, to correct deficiencies, and to provide support to facilitate the ongoing activities of the Utility Program.
6.2Administration receives regular reports on the activities of the Utility Management Program from
the EC Committee. The Administrative Team reviews information and, as necessary,
communicates concerns about key issues and regulatory compliance to Facilities Engineering
and/or the EC Committee Chair. The Administrative Team collaborates with Facilities
Engineering/Safety to establish operating and capital budgets for the Utility Management
Program.
6.3Facilities Engineering managesthe Utility Management Program. They identify codedeficiencies, manage the maintenance of utility systems and initiate emergency response. Hospital Education and Human Resources department facilitates the appropriate training of staff, volunteers, and physicians. Facilities Engineering and theSafety Officer advise the EC Committee regarding utility issues which may necessitate changes to policies, orientation or education, or purchase of equipment.
6.4Department heads orient new staff members to the department-specific and, as appropriate, to job- specific utility knowledge and skills. Department heads are responsible for ongoing training of their staff in the basics of utility management knowledge. When necessary, Facilities Engineering and/or the Safety Officer provides department heads with assistance in developing department utility management training and emergency response procedures for their staff.
6.5Individual staff members are responsible for learning and following hospital fire plans. Individual staff members are also responsible for learning and using emergency reporting procedures for fires and fire hazards.
7.PROCESSES OF THE UTILITY SYSTEMS MANAGEMENT PLAN
The organization manages its utility risks (EC.7.10)
7.1Utility Systems Management Plan (EC.7.10.7)
7.1.1A Memorial Hermann Hospital Facility maintains a written management plan describing the processes it implements to manage the effective, safe, and reliable operation of utility systems. This plan is evaluated annually, and revised as necessary, based on changes in conditions, regulations and standards, and identified needs.
7.2Design and Maintenance of Utility Systems (EC.7.10.8)
7.2.1Facilities Engineering is responsible for managing the planning, design, construction, and commissioning of utility systems to meet the patient care and the operational needs of a Memorial Hermann Hospital System facility. The construction and commissioning programs are designed to assure compliance with codes and standards and to meet the specific needs of the occupants throughout the institution. Facilities Engineering is also responsible for setting maintenance standards and implementing a program of planned maintenance and Customer Service for utility related issues.
7.3Risk Criteria (EC.7.10.9)
7.3.1The organization uses risk criteria to assist with identifying, evaluating, and creating an inventory of operating components of systems to be included in the utility management plan before the equipment is used. A Memorial Hermann Hospital System facility includes all utility systems in its Utility Management program which are reflected in the system inventory.
7.3.2Where appropriate, these risk criteria address the following:
7.3.2.1Life support
7.3.2.2Infection control
7.3.2.3Support of the environment
7.3.2.4Equipment support
7.3.2.5Communication
7.3.3The results of assessment of the various utility systems and components assist with developing maintenance strategies; identify equipment included in preventive maintenance, corrective maintenance and the other types of maintenance used at the facility. The results of assessing the risks of failures of the utility systems are also used to identify those systems and areas for which emergency plans are needed to assure ongoing safety patient care and patient, staff and visitor safety.
7.4Maintenance Strategies (EC.7.10.10)
7.4.1A Memorial Hermann Hospital System facility has developed appropriate strategies for all utility systems equipment on the inventory for ensuring effective, safe, and reliable operation of all equipment in the inventory. These strategies include:
7.4.1.1Preventive and predictive maintenance – for equipment that will benefit by regular inspections and adjustments to the systems.
7.4.1.2Corrective Maintenance – for equipment repairs and replacements on “demand” style basis.
7.4.1.3Other strategies, based on the needs of the equipment, and organization history with that equipment.
All of the equipment on the inventory of a Memorial Hermann Hospital System facility is included as appropriate in these strategies.
7.5Maintenance Intervals (EC.7.10.11)
7.5.1The organization defines the intervals for maintenance, inspection and testing of all equipmentunder preventive maintenance on the inventory. The equipment and the maintenance activity are based upon manufacturers’ recommendations, evaluated risk levels, and facilities experience.The PM activity is scheduled by a maintenance management system that generates work orders on a periodic basis.
7.5.2The results, including over due work orders, compliance rates, and significant deviations are evaluated to determine the effectiveness of the system, the need to replace components, and opportunities to improve by changing intervals and activities. The results of the analysis are used for program improvements and significant issues or trends reported to the EC committee.
7.6Emergency Procedures (EC.7.10.12)
7.6.1The facility hasidentified and implemented emergency procedures for responding to utility system disruptions or failures that address the following:
7.6.1.1What to do if utility systems malfunction (on a departmental and organization wide basis)
7.6.1.2Identification of an alternative source of organization defined essential utilities (where alternate sources are appropriate)
7.6.1.3Shutting off of the malfunctioning systems and notifying staff in affected areas
7.6.1.4How and when to perform emergency clinical interventions when utility systems fail (This is focused on clinical staff and support staff)
7.6.1.5Obtaining repair services (This includes both internal and external resources)
7.6.2The plans for these emergency responses are integrated and/or coordinated with the Emergency Management plans and processes at each facility.
7.6.3These plans are developed to include the criteria and indications for implementing a utility response plan; the staff responsible for making the decisions, activities and resources used to mitigate the emergency (such as an emergency power system to mitigate external power failure); preparation for the failure (e. g., flashlights, staff training about how to respond to a power failure). The recovery plans focus on return to normal conditions, and the resetting and recovery of emergency equipment and supplies.
7.7System Layout and Controls (EC.7.10.13)
7.7.1Facilities Engineering is responsible for managing the process for documenting the layout of utility systems and the locations of critical or emergency controls for a partial or complete shut-down of the system.
7.7.2In addition, they are responsible for maintaining historical documents that graphically illustrate each of the utility systems. New utility systems and major updates to existing utility systems are required to be developed by the architect or engineer and provided to the facility as computerized drawings.
7.7.3Day-to-day use of historical documents and computerized drawings includes additions, deletions, and other changes to the layout of utility systems to be documented in a timely manner. This ongoing process of making changes allows the overall accuracy of the utility system layout to be maintained at a high level at all times.
7.7.4Critical or emergency operating components of utility systems are identified on historical documents, operations manuals or computerized drawings. A variety of techniques such as legends, symbols, labels, numbers, and color-coding are used on to identify the location and type of critical or emergency controls. The corresponding physical control is identified by a tag or other device attached to the device. This process is designed to provide technicians with accurate information about the function of a control before it is activated for scheduled maintenance or during an emergency.
7.8Management of Waterborne Pathogenic Agents (EC.7.10.14)
7.8.1The organization has identified and implemented processes to minimize pathogenic biological agents in cooling towers, domestic hot/cold water systems, and other aerosolizing water systems.
7.8.2When the monitoring program for managing the potential for hospital-acquired infections detects the presence of pathogenic biological agents in water systems, Infection Control and Facilities Engineering collaborate to identify an effective treatment and future prevention program.
7.9Maintenance of Air Pressurization, Filtration, and Filter Efficiency (EC.7.10.15)
7.9.1A Memorial Hermann Hospital System facility designs, installs, and maintains ventilation equipment to provide appropriate pressure relationships, air-exchange rates, and filtration efficiencies for HVAC systems serving areas specially designed to control air-borne contaminants (such as biological agents, gases, fumes, and dust). The air handling and filtration equipment is monitored and maintained by the Facilities Engineering Department on a scheduled basis.
7.9.2A qualified service provider is engaged to verify flow rates (air exchange rates, and positive or negative pressure rates) and pressure relationships as part of the commissioning of building projects and major space renovations. In addition, the air flow rates and pressure relationships are tested periodically throughout the hospital including investigation of complaints related to indoor air quality and as a scheduled maintenance task. The results of testing are used to adjust the performance of HVAC systems.
7.9.3If system performance cannot be adjusted to meet code requirements or occupant needs, the Facilities Engineering works with appropriate Infection Control and clinical staff to develop temporary management practices. In addition, a recommendation for upgrading or replacing the equipment involved is prepared and submitted as part of the normal or emergency capital budget process.
7.10Emergency Electrical Power Systems (EC.7.20)
7.10.1A reliable emergency power source is provided as required by occupancy classification and services provided within a Memorial Hermann Hospital System facility for the following Life/Safety Systems:
7.10.1.1Alarm systems
7.10.1.2Exit route illumination
7.10.1.3Emergency communication systems
7.10.1.4Illumination of exit signs
7.10.2The organization (as appropriate) provides a reliable emergency power system, as required by the services provided and patients, that supplies electricity to the following areas when normal electricity is interrupted:
7.10.2.1Blood, bone, and tissue storage units (in laboratory, OR and other areas)
7.10.2.2Emergency/urgent care areas (Including the ED and selected treatment areas)
7.10.2.3Elevators (at least one for non-ambulatory patients)
7.10.2.4Medical air compressors
7.10.2.5Medical and surgical vacuum systems
7.10.2.6Areas where electrically powered life-support equipment is used (such as Critical care areas)
7.10.2.7Operating rooms
7.10.2.8Postoperative recovery rooms
7.10.2.9Obstetrical delivery rooms
7.10.2.10 Newborn nurseries
7.10.3The Emergency power source is adequately sized, designed, and fueled.
7.11Maintenance, Testing and Inspection of Utility Systems (EC.7.30)
7.11.1A Memorial Hermann Hospital System facility maintains a current documentedinventory of all of the utility components identified by the utility management plan. The inventory is the basis of the maintenance management system.
7.11.2The inventory is updated with addition/deletion of equipment as appropriate. The inventory is maintained in the maintenance management system and in other forms, which are periodically reviewed.
7.11.3Each critical component identified in the plan is subject to performance and safety testing before initial use, as part of the acceptance process, and is included into the inventory at that point. The maintenance management systemschedules and documentsthemaintenance of utility systems/equipment consistent with strategies identified in the utility management plan. Items which are selected for preventive maintenance are included in that program; and other items are maintained by corrective maintenance.
7.11.4The documentation of the maintenance of the utility system components related tothe facility is maintained on the maintenance management system, consistent with strategies identified in the utility management plan.Reports about outcomes of the maintenance program are organized and forwarded to the ECCommittee. Information about significant failures and equipment concerns are also highlighted on those reports.
7.12Emergency Power Systems (EC.7.40).