Hydrostatic tests and water-flow tests on standpipe systems Every 5 years NFPA 25 Hydrostatic tests on standpipe occupant hoses 5 years after installation and 3 years thereafter NFPA 1962 NFPA 25 Dry Chemical Suppression Systems Kitchen automatic fire extinguishing systems Semiannually NFPA 96 Carbon dioxide and other gaseous automatic fire extinguishing systems Annually NFPA 13 NFPA 12A Portable Fire Extinguishers Portable fire extinguishers Inspected monthly Maintained annually NFPA 10 Smoke and Fire Management Systems Smoke and fire dampers Operated for full closure, 1 year after installation and every 6 years thereafter NFPA 90A NFPA 80 NFPA 105 Automatic smoke detection shutdown devices for air handling equipment Annually NFPA 90A Sliding and rolling fire doors. Smoke barrier sliding or rolling doors, and corridor walls and partitions for proper operation and full closure Annually NFPA 80 NFPA 105 Elevators Elevators with fire fighters’ emergency operations Monthly NFPA 101
(d) Deficiencies, problems, failures, user errors (e) Status of the Testing/Inspecting, and Maintenance Program (f) Equipment hazard notices/recalls (4) Monitoring of Performance. (a) Performance monitoring is used to— (1) Identify areas of concern and strengths in the Medical Equipment Program (2) Identify or determine actions necessary to address areas of concern (3) Assess actual compliance with relevant security standards (b) The Chief, Medical Maintenance— (1) Identifies at least one measurable performance improvement project regarding actual or potential risk related to one or more of the following— (a) Employee knowledge and skills (b) Level of employee participation (c) Monitoring and inspection activities (d) Emergency and incident reporting (e) Inspection, preventive maintenance, and testing of equipment (2) Considers high-risk, high-volume or chronic problems when developing performance standards to better focus limited resources. (3) Sets desired goals or benchmarks and develops and implements data collection and reporting procedures. (4) Appendix C lists the Medical Equipment Performance Improvement Projects (s) for this year. (c) The Safety/EC Committee tracks performance and documents the results in the committee’s minutes.
ENVIRONMENT OF CARE UTILITY SYSTEMS MANAGEMENT PLAN 1. Goal 2. Objectives 3. Scope 4. Responsibilities 5. Utility Systems of Performance a. Utility Systems Management Plan b. Risk Assessments c. Risk Management Process d. Design and Installation of Utility Systems e. Technical Library f. Utility Systems Inventory g. Preventive Maintenance Strategies h. Preventive Maintenance Intervals i. Ventilation Systems j. Utility Systems Distribution k. Labeling for Emergency Shutdown l. Utility Systems Disruption Procedures m. Shutting Down Malfunctioning Systems n. Emergency Clinical Procedures o. Emergency Repairs p. Emergency Response q. Inspections, Test, and Maintenance Procedures r. Orientation and Annual Refresher Education and Training s. Information Collection and Evaluation System Note: Additional Information on hazardous energy sources is available in the Hazardous Materials and Waste Management Plan Note: Additional Compressed gas safety procedures are discussed in the Hazardous Materials and Waste Management Plan 1. Goal. This management plan describes the framework to manage risks associated with utility systems and to continuously improve program performance. The scope and objectives are consistent with the Command’s values, vision, and mission to provide 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 ensure the physical safety of patients, visitors, and employees and prevent the loss of property— a. Effectively manage utility system risks through regulatory compliance and by using best industry practices b. Optimize resources by using efficient utility system processes and lifecycle management of equipment c. Improve employee performance through effective education and training d. Improve employee and patient satisfaction by providing a safe physical environment