St.

Luke's Medical Center

E. Rodriguez, Quezon City Legend:
Plan
EMS 14001 & OSHAS 18001 Implementation Plan ( Integrated Management System ) Actual
Main Plan

2009 2010
PDCA

Details Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Remarks
Plan
1 EMS & OHSAS 18001 Standard Awareness Actual acquire EMS 14001/OHSAS 18001 STd
Plan
2 Establishment of Environment and Safety Committee Actual exixting committee or another???
Formulation of Environmental and Safety Top Management Plan
3 Policy Actual existing and improve
Planning of Environmental and Safety programs and Legal Plan
4 requirment compliance Actual existing and improve
Creation of cross-functional teams from different levels of Plan
5 organization Actual existing or establish
Gap analysis ( existing management system vs. standard Plan
Plan

6 requirements ) Actual
Creation of Level 1 documents for environment and safety Plan
7 based on Standard Actual
Environmental aspect identification and Safety Hazard Plan
8 assessment Actual formulate checklist
Plan
9 Inventory and list of all chemicals used including MSDS Actual
Management programs establishment for Safety and Plan
10 environment Actual
Plan
11 Establishment of facility, process and procedure control Actual existing and improve
Establishment of management system documentation per Plan
do

12 department, unit or group ( based on safety & environment ) Actual existing and improve
Plan
13 Initial Top Mangement Review Actual
chcek

Plan
14 Initial Third Party Assessment Actual
Plan
15 Findings countermeasure plan and implementation Actual
action

Plan
16 Final 3rd party certification Actual

Prepared By:

Bencio G. Dy
St. Luke's Medical Center
E. Rodriguez, Quezon City

EMS 14001 & OSHAS 18001 Implementation Plan ( Integrated Management System )
Detailed Activities

List of Activities 2009 2010 Resources Estimated PIC

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Needed Cost ( Php) Main Support
1.0 Documentation of policies and procedures under level 1 for enviromental and safety. Stationaries supplies/datas of department Dept./Unit
2.0 Review ,establishment and collect process,facility and procedure control Datas of department/unit Dept/Unit/Div.
3.0 Established Environmental and safety management programs. Datas of department/unit Dept/Unit/Div.
4.0 Establishment of Internal audit team for Environment and safety
5.0 Establishment of audit checklist for environment and safety criteria
6.0 Appointment of EMR ( Environmental Management Representative ) Management Support Management
7.0 Selection of third party certification for environment and safety including cost estimation of certification Internet Access/Sourcing IMD Purchasi
8.0 Selection of outside consultant for environment and safety management system. Internet Access/Sourcing/Financial 150,000.00 IMD Purchasi
7.0 Meeting with working group regarding progress of project. Cross-functional meeting Dept./Unit
1.0 Documentation of policies and procedures under level 1 for enviromental and safety. Stationaries supplies/datas of department/cp/manpower Dept./Unit
2.0 Finalized Environmental and safety management programs. Datas of department/unit Dept/Unit/Div.
3.0 Meeting with working group regarding progress of project. Cross-functional meeting Dept./Unit
1.0 Finalized and approved documentation of policies and procedures under level 1 for enviromental and safety. Stationaries supplies/datas of department/cp/manpower Dept./Unit
2.0 Conduct initial audit of Environmental and Safety Management System audit team Dept./Unit
3.0 Meeting with working group regarding progress of project. Cross-functional meeting Dept./Unit
1.0 Conduct initial management Review ( input the result of internal audit ) Management Support Management
2.0 Plan and implementation of countermeasures for Environment and safety audit findings. support of units Dept/Unit/Div.
3.0 Plan and improvement implementation of third party audit findings. ( consultant ) support of units Dept/Unit/Div.
3.0 Meeting with working group regarding progress of project. Cross-functional meeting Dept/Unit/Div.
1.0 Implementation of countermeasures for Environment and safety audit findings. support of units
2.0 Final improvement implementation of third party audit findings. ( consultant ) Management Support
3.0 Final management Review ( follow up progress of implementation, GO no GO for certification ) Management Support

1.0 Third party certification Financial Support 2,000,000.00

2,354,000.00
St. Luke's Medical Center
E. Rodriguez, Quezon City

EMS 14001 & OSHAS 18001 Implementation Plan ( Integrated Management System )
Detailed Activities
2009 Resources Estimated PIC Remarks
List of Activities Jun Jul Aug Sep Oct Nov Dec Needed Cost ( Php) Main Support
1.0 Acquire EMS: ISO 14001 and OHSAS 18001 Management System thru BPS Env./Safety Standards/Financial 2,000.00 EMD
2.0 Make presentation materials for EMS:14001 & OHSAS 18001 Computer
3.0 Coordinate with training department regarding schedule of presentation
4.0 Brainstorming meeting within EMD-Safety and Environment Group
5.0 Inventory list of all chemicals use in SLMC. Datas of department/unit Dept./Unit
6.0 Research for cost incurred for third party certification and consultation fee Internet Access
7.0 Research and study OSHA Handbook Internet Access
8.0 Training and Awareness of every department, group and unit. Training Material / computer Training Dept
9.0 Campaign drive by posting ISO 14001 awareness and OHSAS 18001 Brochures / signages/ Financial 20,000.00
10.0 Solicite commitment of every heads,unit and section managers and associates
in the achievement of EMS: ISO 14001 AND OHSAS 18001 management system
11.0 Establishment of Environment and Safety Committee ( Top managent down to Section Manager )
12.0 Formation of working committees on Environmental and safety management systems.
13.0 Continue Inventory list of all chemicals use in SLMC. Datas of department/unit
14.0 Benchmarking with other hospitals with EMS 14001 Certification
15.0 Make a format of compliance checklist
16.0 Formulation of Environmental and Safety Management Policies & Programs Top Management Forum
17.0 Documentation list of all legal requirements and licences ( National & local & internaltional if applicable ) Internet Access
18.0 Gather statistical data regarding electricity consumption, water consumption , waste utilization and even Datas of department/unit EMD/Infectious C./
hazardous chemicals utilization for possible establishment of management programs for safety & environment
19.0 Schedule meetings of working group to assess the progress. Cross-functional meeting Dept/Unit/Div.
20.0 Create forms for Environmental aspect identification and Hazard assessment. Computer /Manpower IMD
21.0 Gather statistical data regarding accidents, incidents and emergency happen Datas of department/unit Dept./Unit
22.0 Finalized list of all chemicals used in SLMC. Datas of department/unit Dept./Unit
23.0 Formulate Impact assessment criteria Safety
24.0 Perform brainstorming and gap analysis vs.environmental and safety management standard.
25.0 Conduct Environmental aspect and impact and risk assessment. Datas of department/unit/ manpower Dept/Unit/Div.
26.0 Finalized the list of all legal requirements and licences ( National & local & internaltional if applicable )
27.0 Review waste management System Datas of department/unit Infectious C./
28.0 Meeting with working group regarding progress of project. Cross-functional meeting Dept/Unit/Div.
29.0 Processed Environmental aspect and impact and risk assessment gathered data. Datas of department/unit Dept/Unit/Div.
30.0 Make action plan for the result of gap analysis of environmental and safety standard.
31.0 Perform WEM ( Work Environment Measurement ) Test Internet Access/Sourcing 150,000.00 IMD Purchasing
32.0 Review and collect process,facility and procedure control Datas of department/unit Dept/Unit/Div.
33.0 Meeting with working group regarding progress of project. Cross-functional meeting Dept/Unit/Div.
34.0 Documentation of policies and procedures under level 1 for enviromental and safety Stationaries supplies/datas of department 32,000.00 Dept./Unit
35.0 Finalized environmental aspect and impact and risk assessment gathered data. Datas of department/unit Dept/Unit/Div.
36.0 Meeting with working group regarding progress of project. Cross-functional meeting Dept./Unit
37.0 Review ,establishment and collect process,facility and procedure control Datas of department/unit Dept/Unit/Div.
38.0 Established Environmental and safety management programs. Datas of department/unit Dept/Unit/Div.
39.0 Establishment of Internal audit team for Environment and safety
40.0 Establishment of audit checklist for environment and safety criteria
41.0 Appointment of EMR ( Environmental Management Representative ) Management Support Management
42.0 Selection of third party certification for environment and safety including cost estimation of certification Internet Access/Sourcing IMD Purchasing
43.0 Selection of outside consultant for environment and safety management system. Internet Access/Sourcing/Financial 200,000.00 IMD Purchasing
44.0 Meeting with working group regarding progress of project. Cross-functional meeting Dept./Unit
45.0 Finalized Environmental and safety management policies & programs. Datas of department/unit Dept/Unit/Div.
46.0 Finalized and approved documentation of policies and procedures under level 1 for enviromental and safety. Stationaries supplies/datas of department/cp/manpower Dept./Unit
47.0 Conduct initial audit of Environmental and Safety Management System audit team Dept./Unit
48.0 Meeting with working group regarding progress of project. Cross-functional meeting Dept./Unit
49.0 Conduct initial management Review ( input the result of internal audit ) Management Support Management
50.0 Plan and implementation of countermeasures for Environment and safety audit findings. support of units Dept/Unit/Div.
51.0 Plan and improvement implementation of third party audit findings. ( consultant ) support of units Dept/Unit/Div.
52.0 Meeting with working group regarding progress of project. Cross-functional meeting Dept/Unit/Div.
53.0 Implementation of countermeasures for Environment and safety audit findings. support of units
54.0 Final improvement implementation of third party audit findings. ( consultant ) Management Support
55.0 Final management Review ( follow up progress of implementation, GO no GO for certification ) Management Support
56.0 Third party certification Financial Support 400,000.00
804,000.00
outline
1 Background of EMS, Safety management system
2 Benefits that the organization can derived
3 Some accredited EMS & Safety certified in the industry
4 Element of the standards
5 Timetable of implementation

Activities time frame Resources Estimated Responsible remarks

needed cost safety hr
Safety & Enviromental Management Committee

President & CEO

Quality Management
Director

SVP- Medical Affairs

Environment Mnagement
Representative/SO/PCO

Infectious Control Finance Support Nursing Division Supply Chain Human Resources
Service/Housekeeing/
EMD
Waste Management Financial Resources Facility Management Core Operation Supply Training & Development
Control Recyclable waste
Environment and Safety Working Committee

FSHE
Group Team Leader
Emergency Preparedness

EMS & OSHAS

Secretariat

Research D & B Infectious Control EMD/Housekeeping Nursing Department Supply Chain Human Resources AMSD

Chemical Handling & Waste Management Facility Management Core Operation Supply Training & Developme Document & Data Control
Control Safety Logistics
Environment and Safety Audit Team

FSHE
Group Lead Auditor

Research D & B Infectious Control EMD/Housekeeping Nursing Department Supply Chain Human Resources

Chemical Handling & Waste Management Facility Management Core Operation Supply Training & Development
Control Safety

Objective:
1.0 To developed and device audit system for Environment and Safety .