UTILITY SYSTEMS MANAGEMENT PLAN



YOUR HOSPITAL

2006 UTILITY SYSTEMS MANAGEMENT PLAN

EC.7.10.7

I PURPOSE

Your Hospital exists to benefit the people of our region by promoting good health, and by healing, caring and comforting. Consistent with this mission, Your Hospital has established and provides ongoing support for the utility management program described in this plan.

The purpose of the Utility Systems Management Plan is to support a safe patient care environment at Your Hospital by managing risks associated with the operation and maintenance of utility systems. The plan includes processes for selection, operation and maintenance, and training designed to assure safe, effective performance of utility systems.

The utility systems program is designed to support patient safety and effective care by providing reliable information that allows facility management and staff to make better utility systems decisions and to evaluate key issues and opportunities for improvement of the utility systems performance.

II SCOPE

The utility systems program is designed to assure design and installation of appropriate utility systems equipment to support the medical care processes of Your Hospital. 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.

III FUNDAMENTALS

A. 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.

B. 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.

C. Critical components of utility systems require maintenance to minimize the potential for failures.

D. Emergency response procedures are required to manage utility system failures or service disruptions.

IV OBJECTIVES

A. The management plan describes the management processes used to assure that the utility systems are designed and maintained to assure a safe and effective care environment, and is reviewed and updated at least annually

B. An assessment of the risks and consequences of utility system failure is conducted annually. Changes in identified risks are included in changes in the procedures, training, and/or equipment provided.

C. The criteria for selection of the appropriate maintenance strategy in the utility systems inventory are reviewed annually.

D. The preventive maintenance program includes tests and inspections for each item or class of items in the preventive maintenance elements of utility systems management program, and these are reviewed annually. Any required changes are reported to the Environment of Care (EOC) Committee.

E. Medical gas system components are tested and inspected at least annually and results reported to the EOC Committee.

F. The process to test and certify medical gas system piping and systems is current, and is verified following any invasive maintenance, or construction and reported to the EOC Committee.

G. The processes used to control pathogenic biological organisms in the chilled water, domestic water, and protective water systems are evaluated annually, and reported to the EOC Committee

H. The processes used to control infection by maintenance of pressure relationships and maintaining filtration are evaluated annually, and the results reported to the EOC Committee.

I. Operational plans for normal and urgent operations of utility system elements are evaluated for current accuracy annually, and results reported to the EOC Committee.

J. The processes used to document, analyze and evaluate utility system problems failures and errors is used to make reports to the EOC Committee quarterly, and evaluated as part of annual evaluation, and the results reported to the EOC Committee.

K. Performance is measured using the performance monitor, evaluated and reported to the EOC Committee quarterly, and evaluated for appropriateness at least annually, and the results reported to the EOC Committee.

L. Emergency procedures for response to failure or malfunction of utility systems are exercised periodically, evaluated annually, and the results reported to the EOC Committee.

M. Emergency power systems are tested weekly, and preventively maintained at least annually, as defined in governing standards. The results are reported to the EOC Committee.

N. There is an annual evaluation of the scope, objectives, performance and effectiveness of the utility

systems program.

V ORGANIZATION AND RESPONSIBILITY

A. The Board of Directors, through the Quality Council, receives an annual report of the activities of the utility systems program from the EOC Committee. They review reports and, as appropriate, communicate concerns about identified issues and regulatory compliance to the President/CEO. They provide support to facilitate the ongoing activities of the utility systems program.

B. The President/CEO receives reports of the current status of the utility systems program through the Quality Council. The President/CEO reviews the reports and, as necessary, communicates concerns about key issues and regulatory compliance to the VP/Clinical, Home Care and Support Services, Director/Engineering, or other appropriate staff. The President/CEO collaborates with the VP/Clinical, Home Care and Support Services to establish operating and capital budgets for the utility systems program.

C. The Manager/Engineering Services works under the general direction of the Director/Project Management and Engineering. They are responsible for the operation and maintenance of the utility systems and the management of contractors working on the utility systems.

D. Department directors/managers are responsible for orienting new staff to the department and, as appropriate, to job and task specific uses of utility systems. When requested, the Engineering Services department provides assistance.

E. Individual staff members are responsible for learning and following job and task specific procedures for safe utility system operation, maintenance, or use. In addition, individual staff members are responsible for timely reporting of utility system problems.

VI. PROCESSES OF THE UTILITY SYSTEMS MANAGEMENT PLAN

The organization manages its utility risks (EC.7.10)

Utility Systems Management Plan (EC.7.10.7)

Your Hospital maintains a written management plan describing the processes it implements to manage the effective, safe, and reliable operation of utility systems. The management plan describes processes to effectively manage utilities systems that provide a safe, comfortable and efficient care environment for patients, staff, and visitors. This plan is evaluated annually, and changed as necessary, based on changes in conditions, regulations and standards, and identified needs.

Design and Maintenance of Utility Systems (EC.7.10.8)

The Director/Project Management and Director/Engineering are responsible for managing the planning, design, construction, and commissioning of utility systems to meet the patient care and the operational needs of Your Hospital. 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. In addition, the design process is intended to assure performance capability in excess of current needs to help assure that changing demands on utility systems can be managed without major capital investment. The Director/Engineering is responsible for setting maintenance standards and implementing a

program of planned maintenance and customer service to ensure a safe comfortable facility.

Risk Criteria (EC.7.10.9)

The organization has established and uses risk criteria for identifying, evaluating, and creating an inventory of operating components of systems to be included in the utility management plan before the equipment is used.

These criteria address the following:

o life support;

o infection control;

o support of the environment;

o equipment support; and,

o communication.

The results of assessment of the various utility systems and components are used to identify the maintenance strategies, and to identify which equipment may be included in preventive maintenance, corrective maintenance and the other types of maintenance used at Your Hospital.

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.

Maintenance Strategies (EC.7.10.10)

Your Hospital 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 the following.

• Preventive and predictive maintenance – for equipment that will benefit by regular replacement of parts, greasing, or other physical activity; or by regular testing or inspection of the equipment. This testing may be done by Your Hospital staff, outside contractors, original equipment manufacturer’s agents or other competent persons.

• Corrective Maintenance – for equipment deemed to have no maintainable parts, or whose failure will not cause serious risk of harm to patients, staff or visitors.

•

• Timed Maintenance- Maintenance based on an hour meter, or other time measurement, based on the manufacturers recommendations.

• Maintenance prior to use – maintenance based on irregular use, and maintenance prior to use.

• Other strategies, based on the needs of the equipment, and organization history with that equipment.

All of the equipment on the inventory of Your Hospital is included in these strategies.

Maintenance Intervals (EC.7.10.11)

The organization defines the intervals for maintenance, inspection and testing of all equipment under preventive or predictive maintenance on the inventory (the pieces of equipment on the inventory deemed to benefit from scheduled activities to minimize the clinical and physical risks). The equipment and the maintenance activity are based upon manufacturers’ recommendations, evaluated risk levels, and Your Hospital’s experience. Most intervals are annual, semi-annual and quarterly, with few monthly and weekly maintenance activities. The PM activity is scheduled by a maintenance management system that generates work orders on a periodic basis. The work orders are distributed to the appropriate staff, and when complete, the data is entered into the system.

The results, including over due work orders, compliance rates, timeliness rates, and outliers (corrective maintenance needed after PM’s) 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 reported to the EOC Committee, and used internally for program improvements.

Emergency Procedures (EC.7.10.12)

Your Hospital has identified and implemented emergency procedures for responding to utility system disruptions or failures that address the following:

• what to do if utility systems malfunction (on a departmental and organization wide basis);

• identification of an alternative source of organization defined essential utilities (where alternate sources are appropriate);

• shutting off of the malfunctioning systems and notifying staff in affected areas;

•

• how and when to perform emergency clinical interventions when utility systems fail (This is focused on clinical staff and support staff); and,

• obtaining repair services (This includes both internal and external resources).

The plans for these emergency responses are integrated with the Emergency Management (EC.4.10.20) plans, into one plan meeting both requirements.

These 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.

System Layout and Controls (EC.7.10.13)

The Director/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.

The Director/Engineering is responsible for maintaining a variety of historical documents that graphically illustrate each of the utility systems. Historical documents are being converted, as time allows, to computerized drawings. New utility systems and major updates to existing utility systems are required to be developed by the architect or engineer and provided to Your Hospital as computerized drawings.

Day-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 very high level at all times.

Critical or emergency operating components of utility systems are identified on historical documents or computerized drawings. A variety of techniques such as legends, symbols, labels, numbers, and color-coding are used 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.

Management of Waterborne Pathogenic Agents (EC.7.10.14)

The organization has identified and implemented processes to minimize pathogenic biological agents in cooling towers, domestic hot/cold water systems, and other aerosolizing water systems.

When the monitoring program for managing the potential for hospital-acquired infections detects the presence of pathogenic biological agents in water systems, the Director/ Engineering, Manager/Infection Control and the Safety Officer collaborate to identify an effective treatment and future growth prevention program.

Any ornamental water within the facility is periodically treated and the potential aerosol is controlled by ventilation, or other methods acceptable to the Manager/Infection Control..

Maintenance of Air Pressurization, Filtration, and Filter Efficiency (EC.7.10.15)

The Director/Project Management and Director/Engineering designs, installs, and maintains ventilation equipment to provide appropriate pressure relationships, air-exchange rates, and filtration efficiencies for ventilation systems serving areas specially designed to control air-borne contaminants (such as biological agents, gases, fumes, and dust).

The air handling and filtration equipment designed to control airborne contaminants including vapors, biological agents, dust, and fumes is monitored and maintained by the Plant Operations Department. The schedule of regular inspection of filter performance monitoring equipment, air pressure sensing equipment, and airflow rate sensors is managed by the Manager/Engineering Services.

A qualified service provider is engaged to verify volume flow rates (air exchange rates, and positive or negative pressure rates) and pressure relationships as part of the commissioning of all new building projects and major space renovations. In addition, the air volume flow rates and pressure relationships are tested periodically throughout the hospital including investigation of complaints related to indoor air quality. The results of testing are used to adjust the performance of air handling systems by changing control software parameters and mechanical or electrical controls.

If system performance cannot be adjusted to meet code requirements or occupant needs, the Manager/Engineering Services 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 to the President and Board as appropriate.

Emergency Electrical Power Systems (EC.7.20)

Your Hospital provides reliable emergency power systems, both as required by the Life Safety Code requirements for exit illumination and task area lighting. Emergency Life Safety power systems supply emergency power to the following areas when normal electricity is interrupted:

1. alarm systems (e, g, Fire Alarms, and other emergency alarm systems);

2. exit route illumination (Lighting in corridors and other key areas to illuminate exit paths and task areas);

3. emergency communication systems (including the PA system, and emergency phone system elements); and,

4. illumination of exit signs;

The organization 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:

5. blood, bone, and tissue storage units (in laboratory, OR and other areas);

6. emergency/urgent care areas (Including the ED and selected treatment areas);

7. elevators (at least one for non-ambulatory patients) (at least one in each bank);

8. medical air compressors;

9. medical and surgical vacuum systems;

10. areas where electrically powered life-support equipment is used (such as critical care areas);

11. operating rooms;

12. postoperative recovery rooms;

13. obstetrical delivery rooms;

14. newborn nurseries;

Maintenance, Testing and Inspection of Utility Systems (EC.7.30)

Your Hospital maintains a current documented inventory of all of the utility components identified by the criteria in the utility management plan. This inventory includes all equipment maintained by Your Hospital staff, by manufacturers’ representatives, and by contractors. The inventory is the basis of the maintenance management system, as well as other maintenance activity.

The inventory is maintained by addition of new equipment and, as appropriate, replacement components; and removal of equipment no longer in use. The inventory is maintained on the maintenance management system, and in other forms, and brought together periodically to allow analysis and evaluation.

Each critical component identified in the plan is subject to performance and safety testing of before initial use, as part of the acceptance process, and is included into the inventory at that point. The maintenance management system then schedules and documents the maintenance of those critical components of life support utility systems/equipment consistent with maintenance strategies identified in the utility management plan. Items which are selected for preventive and predictive maintenance are included in that program; and other items are maintained by corrective maintenance.

The documentation of the maintenance of the selected critical components related to infection control and utility systems/equipment with an impact on high-risk patients is maintained on the maintenance management system, consistent with maintenance strategies identified in the utility management plan. This equipment is maintained as part of the Category I equipment (Maintain limited patient care, especially those on electrical life support equipment. Power restoration for life safety and critical equipment: 10 seconds).

The documentation of maintenance of the critical components of the non-life support utility systems and components/ on the inventory consistent is documented in the CMMS and by other means, consistent with maintenance strategies identified in the utility management plan. This equipment is maintained as Category II (Maintain limited patient care; no one on electrical life support equipment. Power restoration for life safety and critical equipment:10 seconds) and III equipment (Sufficient power to terminate procedure and exit area/ building. Power restoration 10 seconds. For other essential equipment: delayed restoration - time varies). Reports about the results of maintenance are organized and forwarded to leadership, and the EOC Committee. Information about significant failures and equipment concerns are also highlighted on those reports.

Emergency Power Systems (EC.7.40).

The Manager/Engineering Services is responsible for managing a program of inspection, maintenance, and testing of the essential electrical system. Each system motor/generator set is tested under connected load conditions weekly. Appropriate notice of each test run is forwarded to departments throughout the hospital. Tests will be delayed if a critical medical procedure is underway and unanticipated failure of the essential electrical system would result in immediate life threatening conditions, but testing is conducted within the defined time frames. The generators are exercised weekly rather than the minimum monthly requirement so as to allow the testing of a quarter of the transfer switches with each generator test. This fulfills the requirement for monthly testing of all transfer switches.

Testing is conducted for at least 30 minutes under full connected load. Testing time starts when the generator reaches defined operating conditions, generally full operating temperature of either the exhaust system, or coolant water. Appropriate testing parameters are recorded and evaluated by the Manager/Engineering Services or his designee. Any indication of performance below code requirements or expectations is immediately evaluated to determine the source of the problem and rectified.

If any diesel engine powered motor/generator is not loaded to 30% or more of its nameplate capacity during connected load tests, temperature measurements are made to determine if the exhaust gas temperature reaches or exceeds the manufacturer’s recommended temperature to prevent wet stacking. Any engine failing to meet the temperature recommendation will be exercised annually by connecting it to a dynamic

load bank and performing the three step test process required by NFPA 99 and NFPA 110.

At least once every 36 months, each generator set will be tested for a minimum of four continuous hours under a dynamic or static load that is at least 30% of each generator’s nameplate rating. If a minimum load of 30% of the generator’s nameplate rating cannot be achieved, an assessment will be conducted of the prime movers’ exhaust gas temperature and ensure that the minimum temperature recommended by the manufacturer is met.

If any generator fails during the four-hour test, interim measures are implemented to compensate for any risk to patients, visitors, and staff until the necessary corrections or repairs are completed. These interim measures will include the procurement of additional emergency generator capacity to a minimum of the generator load that failed. Upon completion of the necessary corrections or repairs, a four-hour re-test will be conducted to at least 30% of the generator’s nameplate rating.

All automatic transfer switches are tested monthly. Their performance is generally verified during generator testing, as well as annual maintenance of each switch.

The maintenance program of regular inspection, maintenance, and testing includes starting batteries, fuel stored on site, and engine controls. The Engineering Services staff responsible for each component part of the essential electrical system observes or measures critical operating parameters in accordance with regulations, manufacturer recommendations, and good practice guidelines. All observations and measurements are recorded and reported to the Manager/Engineering Services. All repair, calibration, and replacement needs are acted on immediately to assure system reliability.

The Manager/Engineering Services is responsible for identifying all Stored Emergency Power Supply Systems (SEPSS) supplying power for emergency exits, patient ventilation, fire and life safety equipment, public safety and security, communications, and processes that if disrupted would have serious life safety or health consequences.

In addition to the regularly scheduled inspection, testing, and maintenance activities, the Manager/Engineering Services is responsible for assuring evaluation of the impact of adding new loads to the system during construction or at the request of departments throughout the existing hospital. Any addition of a load that would result in an overloaded or poorly balanced system that could result in a safety shutdown will not be

permitted until a suitable configuration can be designed or upgraded equipment is installed.

Medical Gas and Vacuum Systems (EC.7.50)

Your Hospital maintains a preventive maintenance system on an annual basis to inspect, test, and maintain the critical components of the piped medical gas systems. Components that are maintained include the master signal panels (high and low pressure, transfer from normal to reserve indicators), area medical gas alarms, automatic pressure switches (high and low pressure), zone and main shutoff valves, flexible connectors (where installed), and medical gas outlets.

The PM activity is done by Engineering Services, with the assistance of Respiratory Therapy. Where appropriate, contractors are engaged to conduct the tests and inspections of elements that require special equipment and training. Documentation of the testing is maintained by the Engineering Services department.

Your Hospital uses a specialty contractor, or specially trained staff to test and certify piped medical gas and vacuum systems when the systems are initially installed, modified, or invasively repaired. Testing including verification that there is no cross-connection of piping and outlets; testing the piping for content purity and particulates, and verification that the pipes maintain pressure. Testing is done to demonstrate the system meets at least NFPA 99 and CGA 1 requirements.

The main supply valve and the area shut-off valves of each piped medical gas and vacuum system are labeled with the type of gases, and the areas the valve s to be accessible and clearly labeled. Ongoing environmental rounds and observation are used to assure the valves are maintained clear of obstructions to prompt use, in emergencies. In addition, staff are trained about the locations of the applicable medical gas zone valves which might be needed during emergencies.

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