Malaysian Hospital Accreditation Standards 4th Edition January 2013

SERVICE STANDARD 2 Environmental and Safety Services

PREAMBLE

The Facility shall provide a range of environmental safety programmes organisation wide which ensures safe
patient care and safe working environment. The programmes cover requirements but not limited to fire safety,
safety programme, disaster plans, waste disposal and security services.

Some of these activities may be provided from within the Facility by either its own staff or contract staff, or
outsourced to qualified external contractors.

TOPIC 2.1: ORGANISATION AND MANAGEMENT

STANDARD 2.1.1

Each activity is organised and administered to provide optimum support to the goals, objectives and values of
the Facility and to meet the needs of the Facility, patients, staff and visitors.

CRITERIA FOR COMPLIANCE:

2.1.1.1 There are designated committees based on the complexity of the facilities with clearly defined
Terms of Reference and activities. The committees have:

 Appointment of a Chairperson
 Terms of Reference
 Committee members
 Tenure of membership
 Frequency of meetings

2.1.1.2 The designated committees carrying out their activities ensure the following considerations be
given to:

a) action plans indicating the persons responsible;

b) develop the activities with input from patients, community, medical practitioners, service
staff, and in consultation with other relevant services;

c) monitor and determine compliance with Terms of Reference;

d) ensure practice is consistent with professional standards, guidelines and relevant

legislation;

e) review and revise action plans as required, signed and dated accordingly.

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2.1.1.3 There is an organisation chart which:

a) provides a clear representation of the structure, function and reporting relationships

between the Person In Charge (PIC) and the staff of the Environmental and Safety
Services;

b) is accessible to all staff;

c) includes off-site services if applicable;

d) is revised when there is a major change in any one of the following:

 organisation;
 functions;
 reporting relationships;
 goals and objectives;
 staffing patterns.

2.1.1.4 Regular committee meetings are held to discuss issues and matters pertaining to the operations
of the Environmental and Safety Services. Minutes are kept and accessible to relevant staff.

2.1.1.5 Where more than one committee have interests in the issues of the Environmental and Safety
Services:

a) There is clear committee structure that shows line of reporting.

b) There is evidence of coordination of the actions undertaken or proposed by the

committees.

c) Records shall be kept on actions taken to identify and correct the cause of any problem.

2.1.1.6 The Head of Environmental and Safety Services is involved in the planning, management, and
justification of the budget and resource utilisation of the services.

2.1.1.7 The Head of the Environmental and Safety Services shall ensure that the staff of Environmental
and Safety Services complete incident reports which are discussed by the services with learning
objectives and forwarded to the Person In Charge (PIC) of the Facility.

2.1.1.8 Incidents reported have had Root Cause Analysis done and action taken to prevent recurrence.

2.1.1.9 Appropriate statistics and records shall be maintained in relation to the provision of
Environmental and Safety Services and used for managing the services and patient care
purposes.

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2.1.1.10 Where services are provided by an external source, there is a written agreement between the
external service provider and the Facility stating the requirements for service delivery, including
the following:

a) formal lines of communication and responsibilities between the external service provider
and the Facility;

b) provision of adequate numbers of appropriately qualified personnel to perform their duties;

c) participation, as appropriate, of the external service provider in committees of the Facility;

d) arrangements for adequate pickup and delivery;

e) arrangements for after-hours and emergency services;

f) mechanisms for dealing with problems in service delivery;

g) adequate facilities and equipment for providing the services at the Facility and at the site
of the external services;

h) involvement of the external service provider in safety and quality improvement activities of
the Facility, as appropriate;

i) comply with the appropriate MSQH Standards of Accreditation for Environmental and
Safety Services.

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TOPIC 2.2: HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

STANDARD 2.2.1

The Environmental and Safety Services shall be directed by and staffed with adequate numbers of
appropriately qualified staff as required under relevant regulations and statutory requirements to achieve the
objectives of the services.

CRITERIA FOR COMPLIANCE:

2.2.1.1 The direction by the Head and staffing of each service are provided by individuals qualified by
education, training, experience and certification to meet the demands of the various positions
and to achieve the objectives of the services.

2.2.1.2 The authority, responsibilities and accountabilities of the Head of Environmental and Safety
Services are clearly delineated and documented in a letter of appointment.

2.2.1.3 Sufficient numbers of personnel and support staff with appropriate qualifications are employed to
enable each service to meet the documented purposes.

2.2.1.4 There is a structured orientation programme where new staff are briefed on their services,
operational policies and relevant aspects of the Facility to prepare them for their roles and
responsibilities.

2.2.1.5 There is evidence of a staff development plan which provides the knowledge and skills required
for staff to maintain competency in their current positions as the demands of the positions evolve.

2.2.1.6 There are continuing education activities for staff to pursue professional interests and to prepare
for current and future changes in practice. There is evidence that staff education and
development needs have been appraised and identified. There is also evidence that all staff
have the opportunity to attend on-the-job training, in-service education, and continuing education
programmes appropriate to their work including:

a) additional training to staff in the execution of procedures unique to special areas, such as
the operating rooms, obstetrical units, emergency services, special care units, and
isolation rooms;

b) instructions on environmental control in the prevention of healthcare associated infections

and the roles of the employee in this control;

c) safety measures in hazardous areas such as the central sterilising supply services,
operating theatres, kitchens, workshops, laundry, laboratories, and radiation emission
areas.

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TOPIC 2.3: POLICIES AND PROCEDURES

STANDARD 2.3.1

Documented policies and procedures shall reflect the current knowledge and practice of Environmental and
Safety Services, and they are consistent with the objectives of each service and relevant regulations and
statutory requirements.

CRITERIA FOR COMPLIANCE:

2.3.1.1 The Facility has a written Environmental, Health and Safety Policy statement that is displayed
throughout the hospital. Specific policies and procedures shall support and be consistent with the
Environmental, Health and Safety Policy statement.

2.3.1.2 Policies and procedures are developed in collaboration with staff, medical practitioners,
Management and where required with other external service providers and with reference to
relevant sources involved.

2.3.1.3 Policies and procedures are dated, authorised, signed and reviewed at least once every three
years and revised as required.

2.3.1.4 New and revised policies and procedures are communicated to all staff.

2.3.1.5 There is evidence of compliance with policies and procedures.

2.3.1.6 Copies of policies and procedures, relevant Acts, Regulations, By-Laws and statutory
requirements are accessible to staff.

2.3.1.7 Current reference manuals, pamphlets, journals, and books as well as information and scientific
data from manufacturers concerning their products shall be readily available for reference and
guidance.

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TOPIC 2.4: FACILITIES AND EQUIPMENT

STANDARD 2.4.1

Adequate facilities and equipment are available to enable the Environmental and Safety Services to meet its
goals, objectives and ensure safety.

CRITERIA FOR COMPLIANCE:

2.4.1.1 There is adequate and proper utilisation of space and equipment to enable staff to carry out their
professional and administrative functions.

2.4.1.2 There is documented evidence that equipment complies with relevant national/international
standards, e.g. those set by SIRIM Berhad (Standards and Industrial Research Institute of
Malaysia) and current statutory requirements.

2.4.1.3 There is evidence that the Facility has a comprehensive maintenance programme such as
predictive maintenance, planned preventive maintenance and calibration activities, to ensure the
facilities and equipment are in good working order. The maintenance programme and budget are
reviewed.

2.4.1.4 Where specialised equipment is used, there is evidence that only staff who are qualified and
privileged by the Facility operate such equipment.

2.4.1.5 Provisions are made for the personal comfort of patients and staff. This includes:

 clean and hygienic facilities;

 room temperatures are kept at comfortable levels and adequately ventilated;

 steps are taken to reduce noise in patient and staff work areas.

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TOPIC 2.5: SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

STANDARD 2.5.1

The Head responsible for environmental and safety activities shall ensure the provision of quality performance
with staff involvement in the continuous safety and quality improvement activities of the Services.

CRITERIA FOR COMPLIANCE:

2.5.1.1 There is evidence that the Head of the Service has in a written document assigned
responsibilities to appropriate individuals/committees for safety and quality improvement activities
within the services.

2.5.1.2 There are planned and systematic safety and quality improvement activities that monitor and
evaluate the performance of the services including a plan for action and follow up to ensure that
the action taken is effective in continually improving the quality of care. Innovation is advocated.

2.5.1.3 There are safety and quality improvement activities in place which support the Facility’s safety
and quality improvement activities including tracking and trending of specific performance
indicators not limited to but at least two (2) of the following:

a) percentage of staff (includes all on-site outsourced service providers) given orientation
and training in Health and Safety requirements

b) percentage of high level risks identified and corrected

Notes/Explanations

Reports are available on indicators include tracking and trending for specific performance
indicators carried out.

2.5.1.4 Feedback on results of safety and quality improvement activities are regularly communicated to
the staff.

2.5.1.5 Appropriate documentation of safety and quality improvement activities is kept and confidentiality
of staff and patients is preserved.

2.5.1.6 There are safety and quality improvement activities that address staff safety.

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TOPIC 2.6: SPECIAL REQUIREMENTS

STANDARD 2.6.1: FIRE SAFETY

The Facility is constructed, equipped, operated and maintained in a manner that ensures the safety of and
protects its patients, visitors, staff and property from fire.

CRITERIA FOR COMPLIANCE:

2.6.1.1 All buildings comply with relevant legislation relating to fire safety. All fire alarm systems shall be
integrated and linked to the nearest fire station or fire station designated by fire authorities.

2.6.1.2 There is written evidence of fire safety inspection from the appropriate fire authorities. A fire
safety inspection shall have been performed within the last one year, and more recently in the
event of a major building renovation, development or service alteration.

2.6.1.3 There is documented response to recommendations made by the fire authorities, setting out the
action already taken or proposed by the Facility, the rationale on which it is based, and planned
timetable for compliance.

2.6.1.4 There is written evidence of approval from the appropriate government and fire authorities for all
new buildings, renovation works and service alterations. Drawings and design calculations to be
endorsed by certified professional bodies.

2.6.1.5 Automatic fire suppression systems (for example, sprinkler systems) are installed where required
based on recommendations of the local fire authority.

2.6.1.6 Fire fighting equipment (for example, fire extinguishers, hydrants, hose reels, fire blankets) are
located appropriately.

2.6.1.7 All fire fighting systems and equipment are appropriate to the type of fire most likely to occur in
the area in which they are located; and there is written evidence of regular testing and
maintenance being performed at least annually.

2.6.1.8 Approved fire detection and alarm systems (such as smoke detectors or manual fire alarms) exist
throughout the Facility and are in working order.

2.6.1.9 Placement of signs for fire fighting equipment allows for ready identification of equipment, and
“EXIT” (KELUAR) signs at the main corridors and exit doors are in accordance with regulations.

2.6.1.10 There are adequate “No Smoking” signs posted throughout the Facility.

2.6.1.11 There are appropriate systems in the design and construction of buildings to minimise the risk of
the spread of fire and smoke. (E.g. ventilation systems, compartmentalisation).

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2.6.1.12 Doors to patient rooms and exit doors are not locked from the inside except where specifically
required (for example, psychiatric units). In such cases, there are documented policies and
procedures to ensure adequate access and egress.

2.6.1.13 There is adequate means of egress from all parts of the building in compliance with requirements
of local fire authorities and building regulations. Appropriate notification shall be clearly evident
where dead-end corridors exist.

2.6.1.14 Doorways, corridors, ramps, and stairways that are a means of egress in case of fire are kept
free of obstruction at all times, and are wide enough for the evacuation of non-ambulatory
patients.

2.6.1.15 Fire and smoke doors which can be opened and closed manually are kept closed at all times (no
door stopper allowed). Except where otherwise prescribed, fire and smoke doors may be held
open by electric hold-open devices set to release upon activation of the fire detection system.

2.6.1.16 There is a designated fire safety officer who is trained to be responsible for fire safety issues.

2.6.1.17 a) Fire evacuation floor plan including assembly area locations shall be displayed prominently
in all areas.

b) Fire emergency plans and procedures shall include:

i) the assignment of personnel to specific tasks and responsibilities;

ii) instructions for the use of alarm systems and signals;
iii) information concerning methods of fire containment;
iv) information concerning the location of fire fighting equipment;
v) systems for notification of appropriate persons;
vi) specification of evacuation routes, assembly points, and procedures;
vii) other provisions as the local situation dictates;
viii) emergency resuscitation e.g. Code Blue (adults), Code Pink (children).

2.6.1.18 Fire drills are held regularly for each shift of staff, under varied conditions and:

a) all staff are trained in fire procedures including fire alarm or notification procedures, and
are familiar with the use and operation of the fire fighting equipment available;

b) all staff are aware of the method and route of evacuation from their area;

c) designated staff are trained to physically evacuate non-ambulant patients;

d) there is a written plan available throughout the Facility detailing action to be taken in the
event of patients having to be moved (see details of evacuation drills in the section on
Disaster Plans (Standard 2.6.3);

e) there are written reports and evaluations on all drills, and documentation of staff
attendances.

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STANDARD 2.6.2: SAFETY PROGRAMMES

The management of the Facility promotes occupational safety and health programmes that ensure a safe and
healthy environment for patients, staff and visitors.

CRITERIA FOR COMPLIANCE:

2.6.2.1 a) There is a multidisciplinary committee (or committees) for the purpose of implementing and
maintaining a comprehensive safety programme for patients, staff and visitors, and for
monitoring and reporting on occupational health matters.

b) Where these matters are dealt with by more than one person, team or committee, there is
evidence of effective communication among the groups, e.g. Safety and Health Committee
meeting.

c) In a small Facility, safety matters may be dealt with as items on the agenda in a committee
whose terms of reference encompass various aspects of safety and patient care.

2.6.2.2 Occupational safety and health programmes are carried out in accordance with statutory
regulations.

2.6.2.3 There are planned safety activities that monitor and evaluate the performance of safety
programmes including a plan for action and follow up to ensure that the action taken is effective
in continually improving the quality of service. These activities include:

a) reporting of activities as required by law and regulation;

b) conducting risk management activities such as risk assessment, risk registration and risk
prevention has been implemented, monitored and evaluated. The evidence includes:

i) Data collection
ii) Monitoring and evaluation of the performance
iii) Action plan for improvement
iv) Implementation of action plan
v) Re-evaluation for improvement

Notes/Explanations

Risk register is taken to mean a register which records details of all the risks identified for
an organisation, their grading in terms of likelihood of occurring and seriousness of impact
on the organisation, initial plan for managing each high level risk and subsequent results.

2.6.2.4 There are regular safety inspections to monitor compliance to indoor air quality, health
surveillance and hazardous and chemical risk assessment requirements according to the Safety
Programme.

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2.6.2.5 There is a designated safety officer whose authority, responsibilities and accountabilities for
safety related activities are clearly defined and documented in a letter of appointment.

2.6.2.6 There is evidence that all staff are familiar with safety programmes.

2.6.2.7 There are written environmental, occupational safety and health policies and procedures that are
comprehensive and uniform in their application throughout the Facility.

2.6.2.8 There are written safety procedures specific to potentially hazardous areas, and for hazardous
substances (for example, central sterilising supply services, food services areas, laundries,
laboratories, operating suites, radiation emission areas, special units, and workshops).

2.6.2.9 Special safety measures in the form of policies and procedures, facilities and equipment are
implemented for hazardous areas in accordance with applicable standards and the requirements
of national and local statutory authorities.

2.6.2.10 Personal protective clothing and equipment are provided where required, and their usage are
monitored.

2.6.2.11 All portable gas cylinders are stored, restrained, and secured in accordance with applicable
standards and the requirements of national and local statutory authorities. The requirements are:

a) Oxygen and flammable gases are stored separately from each other.

b) Storage areas are ventilated, built of non-combustible material, and secured as

appropriate.

c) All full gas cylinders are restrained and stored in an upright position.

d) Flammable anaesthetic gases are not used in piped systems.

e) Storage areas are appropriately sign posted including “No Smoking” sign in accordance
with statutory requirements.

2.6.2.12 There is provision of emergency suction apparatus and medical gas supplies in key areas such
as operating suites, special care units, emergency services etc.

2.6.2.13 There shall be provision of alternative light and power supply appropriate to the needs of the
Facility in the event of a failure of the local supply. Uninterrupted power supply shall be provided
for life support systems, essential lights in operating theatres and rooms for interventional
procedures.

2.6.2.14 Safety stores, cold rooms and plant rooms are equipped with self-closing doors or safety latches,
where appropriate.

2.6.2.15 Signs throughout the Facility are clearly displayed, and easy to follow (for example, directional
and safety signs, exits, hand hygiene, smoking and hand phone restrictions).
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2.6.2.16 There are policies on managing the motor vehicles provided for staff and patient use including
requirements for proper maintenance and competency of drivers with valid licences.

2.6.2.17 The Facility shall ensure that noise, excessive smoke, foul odour or dust are minimised.

STANDARD 2.6.3: DISASTER PLANS

The Facility has written plans to deal with internal and external disasters. Plans are coordinated with statutory
and civil authorities as appropriate.

CRITERIA FOR COMPLIANCE:

2.6.3.1 External Disaster Plans

The Facility has an external disaster plan appropriate to its capabilities. When compiling,
consideration shall be given to the following:

a) The disaster plan is developed in consultation with statutory and civil authorities,
emergency services, and representatives of other health service agencies. The plan is to
establish an effective chain of command, clarify matters of jurisdiction, and coordinate the
Facility’s activities with the activities of these agencies.

b) The scope of the Facility’s roles and resources shall be made known to the local police,
fire brigades, the state emergency services, ambulance teams, and the community.

c) The disaster plan provides for:

i) consideration of the type of disasters likely to occur;

ii) effective communication systems within and outside the Facility;
iii) availability of adequate basic utilities and supplies including gas, water, electricity,
food, and essential medical and support materials;
iv) assignment of staff to specific tasks and responsibilities;
v) an efficient system of notifying staff;
vi) defined authority and control;
vii) conversion of all appropriate spaces into clearly defined areas for efficient triage,
patient observation, and immediate care;
viii) transportation arrangements when necessary for prompt transfer of casualties to the
Facility most appropriate for administering definitive care, after preliminary
emergency medical or surgical services have been rendered;
ix) making available a list of casualties and appropriately designed tags to accompany
each casualty;
x) arrangements for the prompt discharge or transfer of current inpatients who can be
moved without harm;
xi) maintaining security in order to keep unauthorised persons away from the triage
area;
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xii) some form of visual identification for staff involved in the plan;
xiii) the establishment of a public information centre and assignment of public relation
duties to a suitable person; a media communication plan will help to provide
organised dissemination of information;
xiv) debriefing and disaster plan review procedures.

d) The external disaster plan is tested for its capability at least once a year in order to:

i) ensure that all staff are provided with training to enable performance of assigned
tasks;
ii) evaluate the effectiveness of the plan;
iii) evaluate and document the exercise;
iv) review and revise the plan as necessary.

e) The external disaster drill is preferably coordinated with the participation of other
community emergency services. However, if this is not practicable, at least the local
aspects of the plan shall be rehearsed.

f) Drills shall involve the medical practitioners, administrative, nursing, and other staff and
external agencies as appropriate.

g) Each department in the Facility is made aware of its function.

2.6.3.2 Internal Disaster Plans

The Facility has an internal disaster plan based on the type of internal disasters likely to occur
and its capabilities.

When compiling, consideration shall be given to the following:

a) Plans for fire, internal disasters, and emergency situations incorporating evacuation
procedures are developed with the assistance of qualified fire, safety, and other
appropriate experts. Emergency situations may include bomb threats, hostage taking,
attempted suicides, drug demand, provision of medical services in areas other than wards
(for example, kitchens, laundry, workshops), explosion, and loss of vital services.

b) Plans include:

i) the assignment of personnel to specific tasks and responsibilities;

ii) instructions for the use of alarm systems and signals;
iii) information concerning methods of hazards management, e.g. fire containment;
iv) information concerning the location of equipment, e.g. fire fighting equipment;
v) systems for notification of appropriate persons;
vi) specification of evacuation routes, assembly points, and procedures;
vii) other provisions as the local situation dictates;
viii) emergency resuscitation e.g. Code Blue (adults), Code Pink (children).

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c) The internal disaster plan is tested for its capability at least once a year in order to:

i) ensure that all staff are provided with training to enable performance of assigned
tasks;
ii) evaluate the effectiveness of the plan;
iii) evaluate and document the exercise;
iv) review and revise the plan as necessary.

d) Staff are familiar with disaster plans that are readily available and displayed throughout the
Facility.

STANDARD 2.6.4: WASTE DISPOSAL

Waste disposal is carried out in accordance with environmental, statutory and legislation requirements.

CRITERIA FOR COMPLIANCE:

2.6.4.1 All types of waste (clinical, cytotoxic, radioactive, spent oil etc) need to be defined, identified and
labelled appropriately according to the Scheduled Waste definitions.

2.6.4.2 Staff that handle waste need to be trained on proper handling and disposal of the waste.

2.6.4.3 General waste and waste requiring special processing are segregated at the point of origin.

2.6.4.4 The labelling and disposal of all waste are as defined in the relevant Acts.

2.6.4.5 The disposal of sharps is in accordance with the requirements of relevant Acts. Needles are not
recapped.

2.6.4.6 Waste requiring special processing shall be handled safely including the use of approved bags
for contaminated waste, protective clothing, and appropriate collection and storage facility prior
to incineration or removal from the site and a mechanism for monitoring such handling.

Notes/Explanations

These procedures include the removal of waste from the site being in accordance with the
requirements of the relevant authorities such as The Environmental Quality Act 1974 (Act 127)
and subsequent amendments and the subsidiary legislation referring to Scheduled Waste,
Prescribed Premises, Prescribed Activities, Prevention and Control of Infectious Diseases Act
1988, Atomic Energy Licensing Act 1984.

2.6.4.7 Refrigeration shall be provided for clinical waste storage room if the waste is stored for more than
24 hours.

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2.6.4.8 There are dedicated transportation vehicles for general waste and waste requiring special
processing from the point of origin to a central collection point.

2.6.4.9 General waste shall be removed daily and the area is kept clean.

STANDARD 2.6.5: SECURITY SERVICES

Security measures are taken to ensure the protection of patients and staff from assault and loss of property;
and the Facility from damage and loss.

CRITERIA FOR COMPLIANCE:

2.6.5.1 There is a security risk assessment done to identify potential security risk in the Facility.

2.6.5.2 Appropriate security measures are taken to ensure the protection of patients, staff and visitors.
These may include control of access, closed-circuit television (CCTV) monitoring, key control,
alarm systems, adequate lighting, and security protection for personal belongings, payroll,
drugs, and other assets of the Facility.

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