PROGRAM

ORIGINAL DATE:
FIRE SAFETY MANAGEMENT PROGRAM
TITLE: March 2006
IDENTIFICATION LAST REVISION DATE:
SA 1055 RH
NUMBER: July 2014
NEXT REVIEW DATE:
HOSPITAL(S) RUMAILAH HOSPITAL July 2015
Sheet No. 1 of 7

1.0 PURPOSE:

1.1 The Fire Safety Management Program of Rumailah Hospital serves to provide a
framework to protect the properties and occupants from fire and smoke in the
facility. The Program aims to conform to the local and international fire safety
requirements. This Program identifies the established policies, programs, and
processes used by Rumailah Hospital to establish and maintain an effective fire
safety management program.

1.2 Fire Safety Management Program supports the mission of which is Rumailah
Hospital (RH) is an integrated tertiary hospital, which provides patient-centered
compassionate care, supported by technology, continuing education and research
in an environment which values teamwork, empowerment, and attracts highly
qualified staff to provide quality care.

2.0 DEFINITION:

2.1 Fire Safety Management Program – a written document on the process of fire
safety
which will support the mission and vision of Hamad Medical Corporation.

3.0 SCOPE:

Rumailah Hospital including satellite units under RH administration:

3.1. RH Main Building
3.2. Communicable Disease Unit
3.3. Communicable Disease Clinic
3.4. Child Development Center
3.5. Prosthetics & Orthotics
3.6. Mail Service/Housekeeping / Engineering Workshop building
3.7. Mental Health Department
3.8. Dermatology Department
3.9. Dentistry & Oral-Maxillo Facial Building
3.10. Pediatric Dentistry Annex
3.11. Physiotherapy Bn Omran
3.12. Medical City Building 16 (Audiology & Pre-integration Program)

Facility Management and Safety (FMS) Regulatory, Accreditation and Compliance Services (RACS)
 PROGRAM

ORIGINAL DATE:
FIRE SAFETY MANAGEMENT PROGRAM
TITLE: March 2006
IDENTIFICATION LAST REVISION DATE:
SA 1055 RH
NUMBER: July 2014
NEXT REVIEW DATE:
HOSPITAL(S) RUMAILAH HOSPITAL July 2015
Sheet No. 2 of 7

3.13. All other department/units/section/area under RH administration

4.0 OBJECTIVES:

4.1 Describe the process, procedures and systems that establish and maintain a fire
safety management program that provides a fire-safe healthcare environment.

4.2 Every Individual working at Rumailah Hospital should have fire safety training
annually as per HMC policy.

4.3 Provide an environment free from fire hazards.

4.4 Provide for the continuous effective function of all life safety features, equipment,
and systems.

4.5 Ensure that all Programning, installation, testing, maintenance, and monitoring of
fire detection, alarm, and control systems are in accordance with the local and
international standards.

4.6 Appropriately manage any fire situation, whether an actual event or a drill.

4.7 Educate staff as to their roles in the Fire Safety Management Program, which
includes the immediate appropriate response but not limited to RACE Procedure,
PASS Technique. Efficiency of awareness will be evaluated by effective monitoring
tool.

5.0 RESPONSIBILITIES:

5.1 CHIEF EXECUTIVE OFFICER: Responsible for approving and disseminating this
Program.
5.2 FMS CHAIRPERSON: Responsible for disseminating, implementing, and
monitoring staff compliance with the Program.
5.3 FIRE SAFETY OFFICER: Responsible for providing overall direction and guidance
in the implementation of Program in all facilities and liaises with the Engineering
Department for any recommendations for improvement and upgrading of the fire
safety systems.
5.4 ASSISTANT FIRE SAFETY OFFICER: Responsible for the implementation of Fire
Safety Management Program, operation, inspection, testing, maintenance, and

Facility Management and Safety (FMS) Regulatory, Accreditation and Compliance Services (RACS)
 PROGRAM

ORIGINAL DATE:
FIRE SAFETY MANAGEMENT PROGRAM
TITLE: March 2006
IDENTIFICATION LAST REVISION DATE:
SA 1055 RH
NUMBER: July 2014
NEXT REVIEW DATE:
HOSPITAL(S) RUMAILAH HOSPITAL July 2015
Sheet No. 3 of 7

repair of the fire protection systems and equipments in the facility and provide
education for the Hamad General Hospital staff.
5.5 FACILITY Management & Safety Committee: Responsible for oversight of the Fire
Safety Management Program for the Rumailah Hospital. The Chairperson or his
Designee-Member represents the facility on the Corporate Safety Committee
5.6 FACILITY PROGRAMNING, DESIGN, AND CONSTRUCTION: Responsible to
ensure that all new construction and building renovations meet all applicable codes
and standards of Fire Safety Management
5.7 ALL RUMAILAH HOSPITAL EMPLOYEES & INDEPENDENT ENTITIES:
Responsible for learning and following job and task-specific procedures for safe
operations as a part of the Program.

6.0 PROCEDURES: Not Applicable.

7.0 ELEMENT OF PERFORMANCE:

7.1 Risk Management:

7.1.1 Rumailah Hospital should implement this Fire Safety Management

Program which complies with local or international fire safety standards.

7.1.2 Semi- annual hazard surveillance inspection, risk assessments and

comprehensive annual evaluations ensure compliance with the Program.

7.1.3 All staff, including outside Contractors and RH staff, are oriented on fire
safety and other safety precautions before they start construction works.

7.1.4 The Fire Safety Officer liaises with the Engineering Department for any
recommendations for improvement and upgrading of the fire safety
systems or as required.

7.1.5 Building compartmentalization procedures for containing smoke and fire.

7.2 FIRE DRILLS:

7.2.1 Fire Drills will be conducted once a year in all areas of the hospital followed
by a written critique of the exercise and action Program/recommendation.

Facility Management and Safety (FMS) Regulatory, Accreditation and Compliance Services (RACS)
 PROGRAM

ORIGINAL DATE:
FIRE SAFETY MANAGEMENT PROGRAM
TITLE: March 2006
IDENTIFICATION LAST REVISION DATE:
SA 1055 RH
NUMBER: July 2014
NEXT REVIEW DATE:
HOSPITAL(S) RUMAILAH HOSPITAL July 2015
Sheet No. 4 of 7

7.2.2 At least 50% of the drills will be unannounced. All employees will be
expected to participate in this dril
7.2.3 Response to a drill will include alarm activation, containment of smoke and
fire by shutting doors, Programning for, and practicing patient evacuation to
areas of refuge (without moving actual patients), and other responses
required by the Program. Those individuals remote from the site of the drills
may not be required to take any action; however, all staff will be trained in
appropriate fire response. Nominated Fire warden (Unit In-charge a the
time of event, has the responsibility for the Patient & Staff Evacuation and
Head Count at Assembly Point. Active participation of the staff will be
evaluated.

7.2.4 Reports of fire drills and recommendations for improvement are sent to
each facility.

7.3 FIRE EQUIPMENT TESTING AND MAINTENANCE.

7.3.1 All fire protection and life safety systems, equipment, and components are
tested and maintained regularly according to the requirements of
associated standards.

7.3.2 The maintenance requirements and schedule are maintained on a chart in

the Computerized Maintenance Monitoring Systems (CMMS), and the
required functions are performed and documented, depending on the
system and service required.

7.4 APPLICABLE LAWS, REGULATIONS, FACILITY INSPECTION

REQUIREMENTS AND IMPLEMENTATION:

7.4.1 Under the guidance and instruction of Hamad Medical Corporation, RH has
identified the laws, regulations, codes of practices and other requirements
that apply to its facilities.

7.4.2 Rumailah Hospital is moving towards compliance with NFPA (National Fire
Protection Association) standards especially with the new facilities under
construction. The applicable requirements or approved alternatives are
implemented and it ensures the conditions of facility inspection reports or
citations are met.

Facility Management and Safety (FMS) Regulatory, Accreditation and Compliance Services (RACS)
 PROGRAM

ORIGINAL DATE:
FIRE SAFETY MANAGEMENT PROGRAM
TITLE: March 2006
IDENTIFICATION LAST REVISION DATE:
SA 1055 RH
NUMBER: July 2014
NEXT REVIEW DATE:
HOSPITAL(S) RUMAILAH HOSPITAL July 2015
Sheet No. 5 of 7

7.4.3 This Program has been developed in order to meet applicable laws,
regulations and other requirements. Programs and budgets are in place for
upgrading or replacing systems, buildings or components needed for the
continued operation of effective fire safety facility.

7.4.4 Smoking is officially prohibited inside the buildings of all RH facilities.

(Refer to Safety Policy SA 1052.).
7.4.5 In mental health units, special arrangement is in place where exit doors
are kept locked with at least 3 sets of available keys carried by assigned
custodians of every shift.

8.0 RISK ASSESSMENT:

8.1 Identification of fire hazards and risks associated with construction or renovation
projects of the hospital and at all areas of the facility is performed by routine and
unscheduled inspections.

8.2 Identify those who may be subjected to harm of fire.

8.3 Evaluation of identified fire risk and examination of existing control measures to protect
the people from potential risks and hazards.

8.4 Documentation and reporting of findings and implementation of corrective measures

based on recommendations.

8.5 Periodic review of the risk assessment process and update if necessary.

Facility Management and Safety (FMS) Regulatory, Accreditation and Compliance Services (RACS)
 PROGRAM

ORIGINAL DATE:
FIRE SAFETY MANAGEMENT PROGRAM
TITLE: March 2006
IDENTIFICATION LAST REVISION DATE:
SA 1055 RH
NUMBER: July 2014
NEXT REVIEW DATE:
HOSPITAL(S) RUMAILAH HOSPITAL July 2015
Sheet No. 6 of 7

9.0 ANNUAL EVALUATION:

9.1 There will be an annual evaluation of the effectiveness of the Fire Safety
Management Program to determine whether it meets Rumailah Hospital needs.
The program objectives, scope, performance and effectiveness will be evaluated.

9.2 The annual evaluation will include a component on staff training, to ensure that all
are equipped to appropriately manage a fire emergency. The evaluation will take
into account the following but are not limited to:

9.2.1 written critique of fire drills,

9.2.2 schedule of fire safety training
9.2.3 fire alarm testing
9.2.4 fire incident reports
9.2.5 fire near-misses

9.3 The annual evaluation should be done by the Facility Management and Safety
Committee with the Fire Safety Officer and his team of Assistants at the Hospital.
The findings of the annual review and recommendations for improvement to the
Fire Safety Management Program should be documented in a report to be
submitted to the Corporate Safety Committee.

9.4 Following the above, the Fire Safety Officer and his Assistants at the Hospital and
staff should take appropriate action to implement the approved recommendations
listed in the annual evaluation report

Facility Management and Safety (FMS) Regulatory, Accreditation and Compliance Services (RACS)
 PROGRAM

ORIGINAL DATE:
FIRE SAFETY MANAGEMENT PROGRAM
TITLE: March 2006
IDENTIFICATION LAST REVISION DATE:
SA 1055 RH
NUMBER: July 2014
NEXT REVIEW DATE:
HOSPITAL(S) RUMAILAH HOSPITAL July 2015
Sheet No. 7 of 7

10.0 STAFF EDUCATION AND TRAINING:

10.1 EDUCATION AND TRAINING

10.1.1 All RH personnel receive a Newcomer’s Orientation safety training class

covering all facets of fire safety topics, including:

10.1.1.1 Area-specific evacuation routes

10.1.1.2 Specific roles at and away from a fire’s point of origin
10.1.1.3 Use and functioning of fire alarm systems
10.1.1.4 Specific roles and responsibilities in preparing for building
evacuation
10.1.2 Location and use of equipment for evacuation or transportation of patients
to areas of refuge

10.1.3 All contractors and independent entities working for the RH are oriented
on the following before they start work within the premise of RH’s
facilities:

10.1.3.1 Fire Safety and general safety policies and procedures of

the Corporation.
10.1.3.2 Whom to contact in case of emergencies.

10.1.4 The staffs of Occupational Health & Safety (OHS) Department go through a
process of continuing education program on fire safety training provided by
the OHS Department.

11.0 REFERENCES:

11.1 Fire Safety Management Plan (2009, 2010, 2011, 2012, 2013)

Facility Management and Safety (FMS) Regulatory, Accreditation and Compliance Services (RACS)