ENVIRONMENT OF CARE FIRE SAFETY MANAGEMENT PLAN 1. Goal 2. Objectives 3. Scope 4. Responsibilities 5. Fire Safety Management Elements of Performance a. Fire Safety Management Plan b. Risk Assessments c. Risk Management Process d. Minimizing Potential for Harm e. Patient Smoking Policy f. Unobstructed Egress g. Fire Response Plan h. Employee Roles i. Fire Drills j. Technical Library k. Preventive Maintenance for Fire Safety Equipment l. Life Safety Code Compliance m. Interim Life Safety Measures n. Orientation and Annual Refresher Education and Training o. Information Collection and Evaluation System 1. Goal. This management plan describes the framework used to manage fire risks and continuously improve safety performance. The scope and objectives are consistent with the Command’s values, vision, and mission in providing quality healthcare to Soldiers, retirees, and their families, and to provide a safe and healthy workplace for all employees. 2. Objectives. The following objectives will prevent human injuries, maintain a physical environment free of physical hazards, and safeguard Army property— a. Effectively manage fire safety risks through regulatory compliance and by using best industry practices b. Optimize resources by using efficient fire safety processes and lifecycle management of facilities c. Improve employee performance through effective fire safety education and training d. Improve employee and patient satisfaction by providing a safe physical environment 3. Scope. This management plan applies to , and all subordinate facilities to include 4. Responsibilities. a. The Safety Manager and the Facility Manager are responsible for developing, implementing, and monitoring this plan. The Safety Manager focuses on the human aspects of fire safety such as safe work practices and emergency response and evacuation. The Facility Manager focuses on the physical aspects of fire safety such as operability of fire safety equipment and the design, construction, and maintenance of buildings.
(2) Both proactive risk assessments (e.g., internal performance improvement data; employee, patient, and family feedback; environmental monitoring; results of failure mode and effects analyses; governmental regulation reviews; association, society, and professional literature reviews; emergency exercise after action reports; preventive maintenance; design reviews; etc.) and reactive risk assessments (incident investigations, medical equipment failure investigations, root cause analyses, etc.) are used to identify trends for which corrective action is needed. (3) The risk assessment process is also used to manage “gray areas” that do not have a clear resolution. An example of a “gray area” is deciding the best way to secure sharps in the Emergency Room. “Gray area” issues are brought to the Safety/Environment of Care (EC) Committee for discussion and resolution. c. EC.02.01.01, EP.3, Risk Management Process. (1) Medical equipment repairers (MERs) work with supervisors and employees to exchange information and educate each other on risks associated with medical equipment. First-line supervisors are responsible for making sure users are trained and competent in the capabilities, limitations, safe operation, and emergency procedures for the medical equipment that they use. (2) To manage risk and minimize potential harm to patients, employees, and visitors, equipment users identify and isolate faulty or broken broken equipment to avoid use until repairs are made. d. Selection and Acquisition. The selection process begins in the department that will use the equipment. After a request is made, but before acquisition, the Chief, Medical Maintenance participates in the formal review process to assess any risks associated with the equipment; to make sure that the equipment meets the user’s needs and that it is compatible with existing equipment; to evaluate maintenance requirements; to determine space and utility needs; and to determine education and training requirements. e. EC.01.01.01, EP.3, Technical Library. The Facility Manager maintains a technical library related to the inspection, testing, and maintenance of the utility systems installed at HEALTHCARE FACILITY NAME. The library includes manufacturer’s manuals and technical bulletins. f. EC.02.04.01, EP.2, Medical Equipment Inventory. The Chief, Medical Maintenance uses the following risk criteria to evaluate new equipment and to create the medical equipment inventory— (1) Equipment function (life support, monitoring, treatment, diagnostic, and patient support) (2) Physical risks associated with its use