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MSQH 4th Edition: Standard 2- Environment and Safety Services Survey Questionnaires

MSQH 4th Edition: Standard 2- Environment and Safety Services survey questionnaires.

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MSQH 4th Edition: Standard 2- Environment and Safety Services Survey Questionnaires

  1. 1. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 1 SERVICE STANDARD 2: Environmental and Safety Services Standard No. Survey Item Hospital Rating Surveyor Rating 2.1 ORGANISATION AND MANAGEMENT 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. 2.1.1.1 Based on the complexity of the facilities, there are designated committees on safety, health and environment issues with clearly defined:  Appointment of a Chairperson  Terms of Reference  Committee members  Tenure of membership  Frequency of meetings 2.1.1.2 Each designated committee ensures and documents the following: a) action plans indicating the persons responsible; b) activities with input from patients, community, medical practitioners, service staff, and in consultation with other relevant services; c) monitoring and compliance with Terms of Reference; d) practice is consistent with professional standards, guidelines and relevant legislation; e) review and revise action plans as required, signed and dated accordingly. 2.1.1.3 There is an organisation chart which: a) represents the structure, function and reporting relationships between the Person In Charge (PIC) and the staff of the Environmental and Safety Services; Back Print Save Menu
  2. 2. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 2 Standard No. Survey Item Hospital Rating Surveyor Rating b) is accessible to all staff; c) includes off-site services if applicable; d) is revised when there is a major change in any 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 and minutes are available and made accessible to relevant staff. 2.1.1.5 There is documented evidence that 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 coordination of the actions undertaken or proposed by the committees. c) Records are 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 ensures that the staff of Environmental and Safety Services complete incident reports with evidence that these are discussed by the services with learning objectives. These reports are forwarded to the Person In Charge (PIC) of the Facility.
  3. 3. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 3 Standard No. Survey Item Hospital Rating Surveyor Rating 2.1.1.8 There is documented evidence that Root Cause Analysis of all incidents have been done and action taken to prevent recurrence. 2.1.1.9 There are appropriate statistics and records maintained on the provision of Environmental and Safety Services and there is evidence that these are used for managing the services and patient care purposes. 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) arrangement for adequate pick up 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 service; 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.
  4. 4. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 4 Standard No. Survey Item Hospital Rating Surveyor Rating 2.2 HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT 2.2.1 The Environmental and Safety Services are 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. 2.2.1.1 The Head and staff of each service fulfil the educational qualification, training, experience and certification required to meet the demands of the various positions and to achieve the objectives of the services. These requirements are documented. 2.2.1.2 The Head of Environmental and Safety Services has a letter of appointment which delineates the authority, responsibilities and accountabilities of the position. 2.2.1.3 The number of personnel and support staff with the appropriate qualifications employed are sufficient to enable the services to meet the documented purposes. 2.2.1.4 There is evidence that 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 has been implemented. 2.2.1.5 There is documented evidence of implementation 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 as evidenced by: a) Records on staff education and development needs being appraised and identified are available. b) Records on continuing education activities for staff are available.
  5. 5. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 5 Standard No. Survey Item Hospital Rating Surveyor Rating c) A programme for on-the-job training, in-service education, and continuing education for all staff appropriate to their work has been implemented. These should include: i) 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; ii) instructions on environmental control in the prevention of healthcare associated infections and the roles of the employee in this control; iii) safety measures in hazardous areas such as the central sterilising supply services, operating theatres, kitchens, workshops, laundry, laboratories, and radiation emission areas.
  6. 6. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 6 Standard No. Survey Item Hospital Rating Surveyor Rating 2.3 POLICIES AND PROCEDURES 2.3.1 Documented policies and procedures 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. 2.3.1.1 There is an Environmental, Health and Safety Policy statement that is displayed throughout the hospital. There are documented specific policies and procedures to support the Environmental, Health and Safety Policy statement. 2.3.1.2 There is documented evidence that 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 There is evidence of staff acknowledgement that policies and procedures including new and revised ones 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 are readily available for reference and guidance.
  7. 7. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 7 Standard No. Survey Item Hospital Rating Surveyor Rating 2.4 FACILITIES AND EQUIPMENT 2.4.1 Adequate facilities and equipment are available to enable the Environmental and Safety Services to meet its goals, objectives and ensure safety. 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 There is evidence that specialised equipment is operated by staff with appropriate qualification and privileged by the Facility. 2.4.1.5 There is evidence that provisions are made for the personal comfort of staff and patient. This includes:  clean and hygienic facilities;  room temperatures are kept at comfortable levels and adequately ventilated;  steps taken for reduction of noise in patient and staff work areas.
  8. 8. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 8 Standard No. Survey Item Hospital Rating Surveyor Rating 2.5 SAFETY AND QUALITY IMPROVEMENT ACTIVITIES 2.5.1 The Head responsible for environmental and safety activities ensures the provision of quality performance with staff involvement in the continuous safety and quality improvement activities of the Services. 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 documented plans for systematic safety and quality improvement activities that include: a) Planned activities b) Data collection c) Monitoring and evaluation of the performance d) Action plan for improvement e) Implementation of action plan f) Re-evaluation for improvement 2.5.1.3 There are safety and quality improvement activities in place that include 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 2.5.1.4 There is evidence that feedback on results of safety and quality improvement activities are regularly communicated to the staff.
  9. 9. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 9 Standard No. Survey Item Hospital Rating Surveyor Rating 2.5.1.5 Records on safety and quality improvement activities are kept and confidentiality of staff and patients is preserved. 2.5.1.6 There is documented evidence of safety and quality improvement activities that address staff safety.
  10. 10. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 10 Standard No. Survey Item Hospital Rating Surveyor Rating 2.6 SPECIAL REQUIREMENTS 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. 2.6.1.1 Fire Safety : Building and Fire Alarm a) There is evidence that all buildings comply with relevant legislation relating to fire safety. b) All fire alarm systems are integrated and linked to the nearest fire station or fire station designated by fire authorities. 2.6.1.2 There are documented reports of fire safety inspection by the fire authorities (BOMBA) available. Fire inspection should be 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 evidence of planned timetable for compliance and implementation of recommendations made by the fire authorities. 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 There is evidence of automatic fire suppression systems (for example, sprinkler, deluge or clean agent systems) 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.
  11. 11. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 11 Standard No. Survey Item Hospital Rating Surveyor Rating 2.6.1.7 Fire Safety : Systems and Equipment a) All fire fighting systems and equipment are appropriate to the type of fire most likely to occur in the area where they are located; b) There is documented evidence of regular testing and maintenance of the systems being performed at least annually. 2.6.1.8 There are approved fire detection and alarm systems (such as smoke detectors or manual fire alarms) throughout the Facility and are in working order. 2.6.1.9 There are clear signs for the location of fire fighting equipment. „EXIT (KELUAR)‟ signs are prominently displayed at the main corridors and exit doors in accordance with regulations. 2.6.1.10 There are adequate “No Smoking” signs displayed 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). 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 Fire Safety: Egress a) There is adequate means of egress from all parts of the building in compliance with requirements of local fire authorities and building regulations. b) There should be clear signs to indicate dead-end corridors.
  12. 12. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 12 Standard No. Survey Item Hospital Rating Surveyor Rating 2.6.1.14 Doorways, corridors, ramps, and stairways for egress in case of fire are: a) kept free of obstruction at all times; b) 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 doors which are held open by electric hold-open devices set to release upon activation of the fire detection system. 2.6.1.16 There is a letter of appointment for a designated fire safety officer who is trained to be responsible for fire safety issues. 2.6.1.17 Fire Safety : Fire Evacuation Plan a) Fire evacuation floor plan including assembly area locations are displayed prominently in all areas. b) The Facility has written fire emergency plans and procedures which 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 Safety : Fire Drills a) There are written reports on fire drills held regularly to accommodate staff working at different times (day/night)
  13. 13. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 13 Standard No. Survey Item Hospital Rating Surveyor Rating and under varied conditions. These reports include evaluations on all drills, and documentation of staff attendances. b) The drills ensure: i) 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; ii) all staff are aware of the method and route of evacuation from their area; iii) designated staff are trained to physically evacuate non-ambulant patients; iv) there is a written plan available throughout the Facility detailing action to be taken in the event of patients having to be moved.
  14. 14. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 14 Standard No. Survey Item Hospital Rating Surveyor Rating 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. 2.6.2.1 Safety Programmes: Committee a) There is a multidisciplinary committee(s) formed 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) Minutes of these committee meetings are available and decisions made are implemented. 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 There is documented evidence that programmes for occupational safety and health are being implemented in accordance with statutory regulations. 2.6.2.3 There is documented evidence of planned safety activities that monitor and evaluate the performance of safety programmes which includes: 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
  15. 15. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 15 Standard No. Survey Item Hospital Rating Surveyor Rating 2.6.2.4 There are reports on regular safety inspections to monitor compliance to indoor air quality, health surveillance and hazardous and chemical risk assessment requirements according to the Safety Programme. 2.6.2.5 The designated safety officer who is trained has a letter of appointment which clearly delineates his authority, responsibilities and accountabilities for safety related activities 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 and implemented 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) and implemented throughout the Facility. 2.6.2.9 There is evidence that special safety measures in the form of policies and procedures, facilities and equipment have been implemented for hazardous areas in accordance with applicable standards and the requirements of national and local statutory authorities. 2.6.2.10 There is evidence that personal protective clothing and equipment are provided where required, and their usage 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.
  16. 16. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 16 Standard No. Survey Item Hospital Rating Surveyor Rating 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” signs 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 Safety Programmes: Power Supply a) There is evidence that the Facility has provision for alternative light and appropriate power supply in the event of a failure of the local supply. b) Uninterrupted power supply is provided for life support systems, essential lights in operating theatres and rooms for interventional procedures. 2.6.2.14 There is evidence that the Facility has equipped safety stores, cold rooms and plant rooms with self-closing doors or safety latches, where appropriate. 2.6.2.15 There are adequate signs which are clearly displayed, prominently visible and easy to follow throughout the Facility. 2.6.2.16 There is evidence of implementation of policies on: a) managing the motor vehicles provided for staff and patient use; b) proper maintenance documented in a log book; c) competency of drivers with valid licences.
  17. 17. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 17 Standard No. Survey Item Hospital Rating Surveyor Rating 2.6.2.17 There is documented evidence that levels of noise, smoke, foul odour or dust are monitored and action taken to minimise if excessive.
  18. 18. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 18 Standard No. Survey Item Hospital Rating Surveyor Rating 2.6.3 Disaster Plan The Facility has written plans to deal with internal and external disasters. Plans are coordinated with statutory and civil authorities as appropriate. 2.6.3.1 External Disaster Plans There is evidence that the Facility has an external disaster plan appropriate to its capabilities which has taken into consideration 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 are 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;
  19. 19. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 19 Standard No. Survey Item Hospital Rating Surveyor Rating 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; 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 are rehearsed. f) Drills involved the medical practitioners, administrative, nursing, and other staff and external agencies as appropriate. g) Each department in the Facility is aware of its function. 2.6.3.2 Internal Disaster Plan There is evidence that the Facility has an internal disaster plan based on the type of internal disasters likely to occur and its capabilities which has taken into consideration the following: a) Plans for fire, internal disasters, and emergency situations incorporating evacuation procedures are developed with
  20. 20. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 20 Standard No. Survey Item Hospital Rating Surveyor Rating 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 such as IT. 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 contingency procedures; vii) other provisions as the local situation dictates; viii) emergency resuscitation e.g. Code Blue (adults), Code Pink (children). 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. 2.6.4 Waste Disposal Waste disposal is carried out in accordance with environmental, statutory and legislation requirements. 2.6.4.1 There is evidence that all types of waste (clinical, cytotoxic, radioactive, spent oil etc) have been defined, identified and labelled appropriately according to the Scheduled Waste definitions.
  21. 21. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 21 Standard No. Survey Item Hospital Rating Surveyor Rating 2.6.4.2 There is documented evidence that staff handling waste have been trained on proper handling and disposal of the waste. 2.6.4.3 There is evidence that the process of segregation at the point of origin of general waste and waste requiring special processing has been implemented. 2.6.4.4 There is evidence that the labelling and disposal of all waste are according to the relevant Acts. 2.6.4.5 There is evidence that 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 is 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. 2.6.4.7 There is evidence that the clinical waste storage room is refrigerated if the waste is not removed for more than 24 hours. 2.6.4.8 There is evidence that 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 There is documented evidence that general waste is removed daily and the area is kept clean.
  22. 22. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 22 Standard No. Survey Item Hospital Rating Surveyor Rating 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. 2.6.5.1 There is documented evidence of security risk assessment done to identify potential security risk in the Facility. 2.6.5.2 There is evidence that appropriate security measures have been implemented to ensure the protection of patients, staff and visitors. These measures include: a) control of access; b) closed-circuit television (CCTV) monitoring; c) key control; d) alarm systems; e) adequate lighting; f) security protection for personal belongings, payroll, drugs, and other assets of the Facility.
  23. 23. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 23 ENVIRONMENTAL AND SAFETY SERVICES HOSPITAL COMMENTS Std. No: __________
  24. 24. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 24 ENVIRONMENTAL AND SAFETY SERVICES SURVEYOR COMMENTS Std. No: __________
  25. 25. Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013 Service Std 2: Environmental and Safety Services Page 25 ENVIRONMENTAL AND SAFETY SERVICES SURVEYOR RECOMMENDATIONS Std. No: __________

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