Facility M anagement Checklist

Facility name
Physical Location
Facility M anagement
hours
License No.
Date & Time
Audit Type: Renew al Concise/ Follow up Adhoc
Name Title/ License no. Name Title/ License no.

HAAD Auditor HAAD Auditor

Name: Name:
Division: Division:
Audit or No.: Audit or No.:

International Patient Safety Goals

1. Improve t he accuracy of pat ient ident ificat ion

2. Improve t he effect iveness of communicat ion among care givers and care recipient s
3. Improve t he safety of using medicat ions and medical devices
4. Reducing t he risk of healt hcare associat ed infect ions
5. Ensuring correct sit e, correct procedure, correct pat ient for all procedures
6. Accurat ely and complet ely reconcile medicat ions across t he cont inuum of care
7. Encourage pat ient s act ive involvement in t heir own care as a pat ient safety st rategy
8. Improve recognit ion and response t o changes in a pat ient ’s condit ion
9. Reducing risk of pat ient harm result ing from falls
10. Reduce t he risk of hospit al fires

P = PRIORITY PSG = PATIENT SAFETY GOALS

No. Ref Auditor Tasks Yes Partial No PSG Comments

A. The facility complies with relevant law s,
regulations, and inspection requirements.
A.1 JCIA, The building is suit able for scope of work 4, 10
P FM S 1 and operat es as per int ernat ional st andards,
ASHRAE, regulat ory requirement s from HAAD and
NFPA, ot her Abu Dhabi government al aut horit ies
IEE and depart ment s.
A.2 HAAD Emergency clinical services are locat ed on
t he ground floor.

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A.3 HAAD, All physical spaces meet t he minimum
AIA, NHS dimension requirement s for t he relevant
services.
A.4 HAAD All locat ions have been provided wit h clear,
appropriat e signage.
A.5 AIA OR st orage space/ area is available, (see A3)

A.6 AIA St orage area/ room of st erile inst rument s is

HAAD available. Posit ive pressure should be
maint ained in t he clean room and negat ive
pressure in t he decont aminat ed room.
B. Risk M anagement, Safety and Security.
B1 JCIA The organizat ion maint ains an 4, 9,
P FM S2 Environment al and Occupat ional Healt h and 10
Safet y M anagement Syst em (EHSM S) t o
ensure safet y and securit y of pat ient s,
families, visit ors and st aff. The syst em must
address t he following areas:
a. Safet y of facilit y physical
environment
b. Securit y
c. Hazardous mat erials
d. Emergencies
e. Fire safet y
f. M edical equipment
g. Ut ilit y syst ems

B.2 HAAD Qualified individuals oversee t he planning, 4, 9,

P st andard implement at ion and document at ion of t he 10
s (JCI – risk management syst em in t he care
FSE.3) environment (safet y officers & safet y
commit t ee)

B3 HAAD St aff members, volunt eers and cont ract

st andard workers are t rained and knowledgeable
s (JCI – about t heir roles in t he hospit al’s plans for
FSE.16) t he facilit y and EHSM S syst em.
B.4 NFPA 99 Line isolat ion syst ems and monit ors inst alled
and t est ed on regular basis aft erwards.
B.5 AIA Posit ive or negat ive pressure is provided and 10
P monit ored for areas requiring different ial
pressure levels according t o t he services
provided in t hose areas.
B.6 AIA & Appropriat e hoods and exhaust devices for, 10
P NFPA radioact ive isot opes and noxious gases or
vapors are provided.

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B.7 NFPA 99 Gas cylinders in st orage are kept in racks or
secured in posit ion wit h t heir cont ent s
clearly ident ified wit h labels / t ags.
B.8 NFPA 99 Rooms or enclosures for st orage of gas
cylinders are labeled wit h safet y/ warning
signs and are well vent ilat ed.
B.9 NFPA 99 Emergency showers & eye wash facilit ies are
available in laborat ory and anywhere any
person can be exposed t o injurious corrosive
mat erials.
C Fire safety
C.1 JCIA, The Facilit y has an implement ed a fire safet y 10
P plan.

C.2 JCIA Fire alarm syst em & fire fight ing syst ems are 10
P available and periodically t est ed and
maint ained. (every 6mont hs as per civil
defense regulat ions)
C.3 JCIA The fire and smoke safet y evacuat ion plan is
t est ed at least t wice a year.
C.4 NFPA 99 Fire exit signs, maps and fire safet y 2, 9,
P procedures are post ed. Evacuat ion rout es 10
are defined and are unobst ruct ed.

C.5 JCIA St aff are t rained t o part icipat e in t he fire

and smoke safet y and evacuat ion plan.

C.6 JCIA Inspect ion, t est ing, and maint enance of 10

P equipment and syst ems are document ed.

C.7 JCIA Suit ably qualified st aff are available for t he

implement at ion of t he plan.

C.8 HAAD The hospit al developed and implement ed a 10

P st andard non-smoking policy.
s (JCI –
FSE.11)
D. M anagement of utilities

D.1 JCIA The organizat ion has a plan, processes and 10

P procedures for management of facilit ies,
buildings and ut ilit ies including wat er,
elect ricit y, HVAC and gases.

D.2 JCIA Availabilit y of backup power supply (UPS 10

P and/ or backup generat or).

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D.3 JCIA Ut ilit ies used for t herapeut ic, diagnost ic and
analyt ic purposes are t est ed for meet ing
accept able int ernat ional st andards (e.g.
medical gases, wat er for dialysis and
laborat ory assays).
D.4 JCIA Elect rical, wat er, wast e, vent ilat ion, medical 10
P gas, and ot her key syst ems are regularly
inspect ed, maint ained, and, when
appropriat e, improved.

D.5 JCIA St aff responsible for inspect ion, t est ing and
maint enance of ut ilit y syst ems are qualified,
t rained and equipped wit h necessary t est
equipment .

D.6 JCIA M aint enance, inspect ion and t est ing dat a is
document ed and ut ilized for improvement .

E HAAD Hazardous materials

st andard
(JCI –
FSE.7)
E.1 JCIA Hazardous mat erials plan is implement ed, 10
P evaluat ed, t his should be comprehensively
document ed.

E.2 Hazardous mat erials and wast e are 10

P ident ified and list ed.

E.3 Procedures for safe handling, st orage and

use of hazardous mat erials are available.

E4 M SDS and appropriat e PPE are available and 10

P easily accessible.

E5 Hazardous mat erials and wast e are labeled

as such.
E.6 Safe disposal procedures of hazardous 10
P mat erials and wast e are available and
according t o t he legal regulat ions and
requirement s.
E.7 Procedures for report ing and invest igat ion
of spills, exposures and ot her incident s are
in place and known by all st aff.
F HAAD Emergency M anagement
st andard
s (JCI –
FSE.8)
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F.1 M ajor int ernal and ext ernal disast ers and
major epidemic event s which pose
significant risks of occurring are ident ified
and an emergency preparedness plan is in
place.

F.2 The plan is t est ed annually including st aff

part icipat ion; t he t est result s are
document ed and evaluat ed. Any changes
are made t o aim for cont inuous
improvement .
G HAAD Security & Safety
st andard
(JCI –
FSE4,5,6)
G.1 A program t o provide safe and secure 9, 10
P physical facilit y is implement ed.

G.2 The hospit al has a document ed, annual,

accurat e inspect ion of physical facilit ies
which must be carried out by specialist
cont ract ors.

G.3 The hospit al plans and budget s for

upgrading or replacing key syst ems,
buildings or component s based on t he
facilit y inspect ion and in keeping wit h t he
law and regulat ion.
Total M et Partially M et Not M et N/ A
Non
priorit
y
Priorit
y

Facility M anagement HAAD Auditor

Name: Name:
Signat ure: Signat ure:
Dat e: Dat e:

Section Head Comments: ………………………………………………………………………………………………………………

……………………………………………………………………………………………………….……………………….………………….…

Name: ……………………………………………Signat ure: ………………………………………. Dat e ……………….…………

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