HVAC system

No 1 Findings Air Quality in OT,NICU,CICU,CCU,CSSD and other critical place Suggestion from Surveyor - To study and submit air flow study (% of fresh & return) and design report to hospital - To do particle count test, Temp & RH test, Air flow volume test and pressure test - To do Air sampling test - To do a statistic graph for the condenser/chilled water leaving and return temperature - To have proper 5S (cobweb) - To settle defects problem between Hospital and JKR immediately (infill) - Air quality monthly check / urgent attention to reactive back BAS system in order to control humidity and temperature - To check pressure for all isolation room

Chiller Plant

3 4

Cooling tower OT (old Hospital)

Isolation room

Medical Gas
No 1 Findings Cylinder gasses that come together with MH Projects No backup Oxygen cylinder (12 x 2 banks) at medical gas room Medical gas study for every wards and clinics Training Suggestion from Surveyor - Farmasi need to condemn and pass to GPT (buy back program) - Hospital need to buy from Gas Pantai Timur Immediately 2

3 4

- FMS should provided a layout of medical gas in old hospital - Engineering and FMS should give some training to the user (valve, handling, etc) - To have proper medical gas system instead of using individual gas cylinder - To reactive back medical gas panel, to have medical gas panel control room

5 6

Block L ( Chest Clinic ) Old hospital (medical gas panel)

Contingency Plan
Redefine Contingency plan with Hospital representative suit to the old building that we have Internal drill/simulation of contingency plan
No 1 2 3 4 5 6 7 8 9 Type of contingency Water Electricity Chiller Lift Clinical waste eHIS Medical Gas PABX Fire What to redefine (must be suit to current condition) Water tank design, action, Electrical design, action Chiller design, action Lift/staircase design, action Clinical waste design?, action? Medical Gas design?, action PABX design, action Fire system design?, action

Electricity
No Findings Suggestion from Surveyor 1 Energy manager - To have registered energy manager for new hospital - electricity usage over than 3000 KW - To standardize old hospital color code to the new hospital -Training - To build a simple drawing of the layout - Program on how to save electricity usage -To rewiring back for the whole block -To do insulation test every location, make sure no leakage

Confusion of standard color code for UPS and genset Plug Simple layout genset and UPS usage should be available Awareness of hospital staff Old hospital wiring

3 4 5

Training & Pamphlets

Surveyor interested in safety training
No Findings Suggestion from Surveyor

Medical Gas / Pamphlets Electrical / Pamphlets Cleansing Contingency Plans Pamphlets Control Room

- To wards, critical units (AVSU, handling, outlet checking and etc)

- To wards, critical units (Genset/UPS plug, Emergency lights and etc) - All areas - Fire, water, electricity, PABX, clinical waste

3 4

- Training for user at control room should include Medical gas panel training

Documentation
No Findings Suggestion from Surveyor 1 QAP Quality Assurance Program QIA Quality Improvement Activities Plant Log book Wards/Clinics Records Incident reports BEMS manual - To have more QAP/QIA program, not only limited to deduction. - To have statistics on the measurement, so that can easily monitor rather than checked by date - PPM records and a specific BEMS equipment (photo therapy usage) - BEMS should gets all the equipment manuals in order to maintain it.

2 3 4 5

QAP / QIA
QIA Quality improvement Activities QAP Quality Assurance Program The QAP is there, but only for the data of deduction how about other root cause? Example - Linen short fall, rising of work orders quantity