PROVIDENCE HEALTHCARE STEVENS COUNTY

Providence St. Josephs Hospital

Original Date: 3/02

Ref. No.: 2080

Total Pages: 9

Subject

Effective Date: 2/1/12

New
Revised
Reviewed

Supersede Dates:3/02, 6/08, 4/09

, 2/10

UTILITY MANAGEMENT PLAN 2012

Approvals
Environment of Care approved 1/25/2012
Policies, Procedures & Forms Committee approved
PHCSC Administrative Team approved

Policy

Procedure

Protocol

Manual Distribution:

Originating Department:

Contributing Departments:

Environment of Care Policy Manual

EOC

All

SCOPE
The Utility Systems Program is designed to assure design and installation of appropriate utility systems
equipment to support the medical care processes of Providence St. Josephs Hospital (PSJH). The program is
also designed to assure effective preparation of staff responsible for the use or maintenance and repair of the
equipment. The program will support a safe patient care environment at PSJH by managing risks associated
with the operation and maintenance of utility systems. The plan includes processes for selection, operation
and maintenance, and training designed to assure safe, effective performance of utility systems and minimize
the potential for organizational acquired illnesses. Finally, the program is designed to assure continual
availability of a comfortable, safe, controlled and effective patient care environment through a program of
planned maintenance, timely repair, and evaluation of all events that could have an adverse impact on the
safety of patients or staff.
The program is applied to PSJH.
FUNDAMENTALS
A. The complexity of utility systems required to support complex patient care continues to increase.
Selecting new or upgraded utility system technology requires research and a team approach to assure all
functional and medical needs are met.
B. Patient care providers also need to know how utility systems support patient care, limitations of system
performance, safe operating conditions, safe work practices, and emergency clinical interventions during
interruptions.
C. Critical components of utility systems require maintenance to minimize the potential for failures.
D.
Emergency response procedures are required to manage utility system failures or service
disruptions.
OBJECTIVES
The objectives for the Utility Systems Program are developed from information gathered during routine and
special risk assessment activities, annual evaluation of the previous years program activities, including
performance measures, and environmental tours of areas for improvement or to reduce identified risks or
concerns. The objectives for the Management Plan are:
A.
B.
C.
D.
E.
F.

Ensure that processes are in place to prevent or minimize injuries or illness related to utility
systems problems.
Ensure safe and reliable operational of the utility systems.
Provide an overview of the processes, implemented under the management plan.
Ensure that processes are in place to review and improve the utilities program.
Define the responsibilities for implementation of the management plan.
Provide instructions for implementing the plan.

ORGANIZATION & RESPONSIBILITY

The Manager of Plant Operations is responsible for:
A.
Implementing, reviewing and maintaining the Utility Systems Management Plan.
B.
Assuring that the requirements of the Environment of Care standards and NFPA codes
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related to the utilities program are met.

Maintaining compliance documentation.
Reporting to EOC Committee on the status of the Utility Systems Management Program.
Implementing, reviewing and revising the annual evaluation of the Utility Systems
Management Plan.
F.
Establish operating and capital budgets for the Utility Systems Program.
G. Responsible for operation and maintenance of the utility systems and management of
contractors working on the utility systems.
C.
D.
E.

Department managers are responsible for:

A.
Developing department specific utility failure plan, if necessary
B.
Educating department staff on their roles and responsibilities under the Utility Systems
Management Plan
C.
Educating department staff on their roles in carrying out the departments utility failure plan.
Employees will:
A. Participate in training programs.
B. Follow department procedure related to utility systems and demonstrate good
judgment in the performance of their duties.
C. Know their roles and responsibilities in safe use of utility systems.
D. Know how to respond to utility system failures within their work areas.
PLANNING AND IMPLEMENTATION ACTIVITIES
The Organization Manages Its Utility Risks
Utility Systems Management Plan
Manager of Plant Operations maintains a written management plan describing the processes it implements to
manage the effective, safe, and reliable operation of utility systems. The management plan describes
processes to effectively manage utilities systems that provide a safe, comfortable and efficient care
environment for patients, staff, and visitors. This plan is evaluated annually, and changed as necessary, based
on changes in conditions, regulations and standards, and identified needs.
Design and Maintenance of Utility Systems
The Manager of Plant Operations is responsible for managing the planning, design, construction, and
commissioning of utility systems to meet the patient care and the operational needs of PSJH. The
construction and commissioning programs are designed to assure compliance with codes and standards and
to meet the specific needs of the occupants throughout the institution. In addition, the design process is
intended to assure performance capability in excess of current needs to help assure that changing demands on
utility systems can be managed without major capital investment. The Manager of Plant Operations is
responsible for setting maintenance standards and implementing a program of planned maintenance and
customer service to ensure a safe comfortable environment.
Risk Criteria
The organization has established and uses risk criteria for identifying, evaluating, and creating an inventory
of operating components of systems to be included in the utility management plan before the equipment is
used and existing equipment.
These criteria address the impact of utility systems on the following:
Life support
Infection control
Support of the environment
Equipment support
Communication

The results of assessment of the various utility systems and components are used to identify the maintenance
strategies, priority status and to identify which equipment may be included in preventive maintenance,
corrective maintenance and the other types of maintenance used at PSJH.
The results of assessing the risks of failures of the utility systems are also used to identify those systems and
areas for which emergency plans are needed to assure ongoing safety patient care and patient, staff and
visitor safety.
Maintenance Strategies
Maintenance strategies have been developed for all utility systems equipment on the inventory for ensuring
effective, safe, and reliable operation of all equipment in the inventory. These strategies include:

Preventive and predictive maintenance for equipment that will benefit by regular replacement
of parts, greasing, or other physical activity; or by regular testing or inspection of the equipment. PSJH
staff, outside contractors, original equipment manufacturers agents or other competent persons, may be
doing this testing.

Corrective Maintenance for equipment deemed to have no maintainable parts, or whose failure
will not cause serious risk of harm to patients, staff or visitors.

Timed Maintenance- Maintenance based on an hour meter, or other time measurement, based on
the manufacturers recommendations.

Maintenance prior to use maintenance based on irregular use, and maintenance prior to use.

Other strategies, based on the needs of the equipment, and organization history with that
equipment.
Maintenance Intervals
The organization defines the intervals for maintenance, inspection and testing of all equipment under
preventive or predictive maintenance (PM) on the inventory (the pieces of equipment on the inventory
deemed to benefit from scheduled activities to minimize the clinical and physical risks). The equipment and
the maintenance activities are based upon manufacturers recommendations, evaluated risk levels, code
requirements and Plant Operations Department staff experience. Most intervals are annual, semi-annual and
quarterly, with monthly and weekly maintenance activities. The PM activity is scheduled by a maintenance
management system that generates work orders on a periodic basis. The work orders are distributed to the
appropriate staff, and when complete, the data is entered into the system. The results, including over due
work orders, compliance rates, timeliness rates, and outliers (corrective maintenance needed after PMs) are
evaluated to determine the effectiveness of the system, the need to replace components, and opportunities to
improve by changing intervals and activities. The results of the analysis are reported to the EOC Committee,
and used internally for program improvements.
Emergency Procedures
PSJH has identified and implemented emergency procedures for responding to utility system disruptions or
failures that address the following:

What to do if utility systems malfunction (on a departmental and organization wide basis);

Identification of an alternative source essential utilities (where alternate sources are appropriate);

Shutting off of the malfunctioning systems and notifying staff in affected areas;

How and when to perform emergency clinical interventions when utility systems fail. (This is
focused on clinical staff and support staff);

Obtaining repair services. (This includes both internal and external resources).
Utility Failure Plan
Emergency procedures implemented in response to system disruptions or failures are defined in the hospitals
utility failure plan. The plan identifies the systems included in the plan. The plan describes both a general
response to utility failures and specific actions to implement in response to the failure of individual utility
systems.
Individual departments may use the hospital utility failure plan or develop departmental specific plans for
utility failure. Hospital staffs are responsible for making decisions and initiating appropriate actions to
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maintain the safety and care of patients during a utility failure event.
Utility failures are reported to Plant Operations. The Manager of Plant Operations and/or Engineering staff
responds to the event, implement corrective action, record the event and investigate the cause.
Code Internal Triage
The hospital has established Code Internal Triage as a uniform utility failure notification process. This is
part of the hospitals emergency response code system. When a utility failure is identified Code Internal
Triage and the name of the failed utility and area(s) affected are announced overhead. Staffs in the affected
areas are responsible for initiating appropriate actions to maintain the safety and care of patients during a
utility failure event.
Utility Failure Event Report
Utility failure event reports are completed by maintenance staff that respond to and investigate the utility
system failure. The report identifies the failed system, impact of the event on patients, visitors, and staff, and
hospital operations. The report also identifies the cause of the failure.
A history of utility failure events is maintained to determine trends in utility system reliability. Reports on the
performance of the utility systems are provided to the hospital EOC committee quarterly.
Emergency Codes / General Staff Response
The hospital has developed and posted in each department a multi page color codes flip chart/Emergency
manual that provides staff with in formation on how to report a utility failure and a quick reference for
appropriate response to specific emergency codes.
System Layout & Controls
The Manager of Plant Operations is responsible for managing the process for documenting the layout of
utility systems and the locations of critical or emergency controls for a partial or complete shut-down of the
system.
The Manager of Plant Operations is responsible for maintaining a variety of historical documents that
graphically illustrate each of the utility systems. Historical documents are being converted, as time allows,
to computerized drawings. New utility systems and major updates to existing utility systems are required to
be developed by an architect or engineer and provided to PSJH as computerized drawings.
Critical or emergency operating components of utility systems are identified on historical documents or
computerized drawings. A variety of techniques such as legends, symbols, labels, numbers, and color-coding
are used to identify the location and type of critical or emergency controls.
Labeling of Controls
Specific utility system controls such as electric panels and plumbing valves, medical air and vacuum, etc are
labeled to support maintenance activities and partial or complete emergency shut downs. These drawings,
diagrams, and labels are updated as utility systems are remodeled or new systems are installed.
Management of Waterborne Pathogenic Agents
The organization has identified and implemented processes to minimize pathogenic biological agents in
domestic hot/cold water systems, and other aerosolizing water systems.
City of Chewelah monitors domestic water supply.
Any ornamental water within the facility is periodically treated and the potential aerosol is controlled by
ventilation, or other methods acceptable to Infection Control.
Maintenance of Air Pressurization, Filtration, & Filter Efficiency
PSJH designs, installs, and maintains ventilation equipment to provide appropriate pressure relationships, airexchange rates, and filtration efficiencies for ventilation systems serving areas specially designed to control
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air-borne contaminants (such as biological agents, gases, fumes, and dust).

The air handling and filtration equipment designed to control airborne contaminants including vapors,
biological agents, dust, and fumes is monitored and maintained by the Plant Operations Department. The
Manager of Plant Operations manages the schedule of regular inspection of filter performance monitoring
equipment, air pressure sensing equipment, and airflow rate sensors.
A qualified service provider is engaged to verify volume flow rates (air exchange rates, and positive or
negative pressure rates) and pressure relationships as part of the commissioning of all new building projects
and major space renovations. In addition, the air volume flow rates and pressure relationships are tested
periodically throughout the hospital including investigation of complaints related to indoor air quality. The
results of testing are used to adjust the performance of air handling systems by changing control software
parameters and mechanical or electrical controls.
If system performance cannot be adjusted to meet code requirements or occupant needs, the Manager of
Plant Operations works with appropriate Infection Control and clinical staff to develop temporary
management practices. In addition, a recommendation for upgrading or replacing the equipment involved is
prepared and submitted to Leadership at PSJH.
Emergency Electrical Power Systems
PSJH provides reliable emergency power systems, as required by Life Safety Code requirements, for exit
illumination and task area lighting. Emergency Life Safety power systems supply emergency power to the
following areas when normal electricity is interrupted:
The hospital provides an emergency electrical power source as required by the LSC occupancy requirements
that supplies electricity to the following areas when normal electrical service is interrupted:
1. Alarm systems (e.g., Fire Alarms, and other emergency alarm systems)
2. Exit route illumination (Lighting in corridors and other key areas to illuminate exit paths and task areas)
3. Emergency communication systems (including the PA system, and emergency phone system elements);
and
4. Illumination of exit signs.
The hospital provides an emergency electrical power source as required by the services provided and patients
that supplies electricity to the following areas when normal electrical service is interrupted:
1.
Blood, bone, and tissue storage units (in laboratory, OR and other areas);
2.
Emergency/urgent care areas (Including the ED, and ACU selected treatment areas);
3.
Medical air compressors;
4.
Medical vacuum systems;
5.
Areas where electrically powered life-support equipment is used (such as Critical care areas);
6.
Operating rooms;
7.
Surgery recovery rooms;
8.
Dietary Kitchen; and
9.
Radiology
Maintenance, Testing & Inspection of Utility Systems
PSJH maintains a current documented inventory of all of the utility components identified by the criteria in
the utility management plan. This inventory includes all equipment maintained by PSJH staff, by
manufacturers representatives, and by contractors. The inventory is the basis of the maintenance computer
management system, as well as other maintenance activity.
The inventory is maintained by the addition of new equipment and, as appropriate, replacement components;
and removal of equipment no longer in use. The inventory is maintained on the maintenance computer
management system, and in other forms, and brought together periodically to allow analysis and evaluation.
Each critical component identified in the plan is subject to performance and safety testing before initial use,
as part of the acceptance process, and is included into the inventory at that point. The maintenance computer
management system then schedules and documents the maintenance of those critical components of life
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support utility systems/equipment consistent with maintenance strategies identified in the utility management
plan. Items selected for preventive and predictive maintenance, are included in that program; and other items
are maintained by corrective maintenance.
The documentation of the maintenance of the selected critical components related to infection control and
life support utility systems/equipment with an impact on high-risk patients is maintained on the maintenance
computer management system, consistent with maintenance strategies identified in the utility management
plan.
The documentation of maintenance of the critical components of the non-life support utility systems and
components on the inventory is documented in the maintenance computer management system and by other
means, consistent with maintenance strategies identified in the utility management plan. Reports about the
results of maintenance are organized and forwarded to leadership,
and the EOC Committee. Information about significant failures and equipment concerns are also included
in those reports.
EMERGENCY POWER SYSTEMS
Testing emergency power generators
The emergency power generators are tested a minimum of 12 times per year. The tests are no less than 20 or
more than 40 days apart. The generators are tested for a minimum of 30 continuous minutes under the
connected load that is equal to at least 30% of the nameplate rating of the generator.
If the connected load is less than 30% of the nameplate rating temperature, measurement will be made to
determine if the exhaust gases reaches or exceeds the manufactures recommended minimum temperature to
prevent wet stacking.
Any generator that is loaded is less than 30% of the nameplate rating and fails to achieve the manufactures
recommended minimum temperature to prevent wet stacking will exercised annually by connecting the
generator to a dynamic load bank and performing the three step test process required by NFPA 99 and NFPA
110.
Testing automatic transfer switches
All automatic transfer switches are tested as part of the monthly generator load test. Their performance is
generally verified during generator testing, as well as annual maintenance of each switch.
Testing battery powered egress lighting
An inventory of battery powered egress lighting is maintained in the physical plant. Battery powered egress
lighting is tested at 30-day intervals for minimum of 30 seconds.
In addition battery powered egress lighting is tested annually for duration of 90 minutes.
Testing records for battery powered egress lighting is maintained in the physical plant.
Testing stored emergency power supply systems
An inventory of stored emergency power supply systems are maintained in the physical plant. Stored
emergency power supply systems are tested quarterly for a minimum of 5 minutes or as specified for its
class, which ever is less.
In addition stored emergency power supply systems are tested at full load for 60% of the duration for its
class.
The test procedures and reports are maintained in Plant Operations.
36 Months/4 Hour Generator Load Test
The hospital generators are tested at least every 36 months (3 years) under load (dynamic or static) that is at
least 30% of name-plate rating.
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MEDICAL GAS & VACUUM SYSTEMS

The medical gas and vacuum systems are maintained, tested and inspected. Testing records for both of these
systems are maintained in the Plant Operations Department.
Plant Operations Department maintains a preventive maintenance system on an annual basis to inspect, test,
and maintain the critical components of the piped medical gas systems. Components that are maintained
include the master signal panels (high and low pressure, transfer from normal to reserve indicators), area
medical gas alarms, automatic pressure switches (high and low pressure), zone and main shutoff valves,
flexible connectors (where installed), and medical gas outlets.
Plant Operations staff and qualified contractors complete the PM activity, with the assistance of clinical
department managers. Where appropriate, contractors are engaged to conduct the tests and inspections of
elements that require special equipment and training. The Plant Operations Department maintains
documentation of the testing.
Flexible connectors that are part of anesthesia gas machines are inspected and tested by Biomedical
Engineering.
Plant Operations Department uses a certified contractor to test and certify piped medical gas and vacuum
systems when the systems are initially installed, modified, or invasively repaired.
Medical Gases and Vacuum installation testing
Medical gas and vacuum systems are inspected and tested when new systems are installed or existing
systems are modified or repaired. The procedure includes testing for cross connections, purity, and pressure.
Medical Gas and Vacuum valves are accessible and labeled
The main supply valves and area shut off valves of each piped medical gas system are labeled. The labels
identify the gas or vacuum system, and the area the valve controls.
Accessibility to main supply valves and area shut off valves is maintained by period maintenance
environmental inspections.
MONITORS AND IMPROVES CONDICTIONS IN THE ENVIRONMENT
A history of Utility System failure events is maintained to determine effectiveness in the Utility Management
program and identify opportunities for improvement. Reports on the performance of the Utility Management
program are provided to the hospital EOC committee quarterly.
Reporting and Investigating Utility systems management problems & failures
Plant Operations continuously monitors the performance of the utility systems, document and investigates
utility failure events. The physical plant manager reports quarterly on the performance of the utility systems
through the Campus Safety Committee. The reports summarizes the general performance of the utility
systems, identifies trends, and specific failure events that occur during the reporting period. Significant
utility failure events are reported verbally to the campus safety committee at the next meeting of the
committee after the event.
Performance Monitoring
Plant Operations monitors the performance of all utility systems included in the plan. In addition, Plant
Operations monitors key indicators to determine if the objectives of the utility management program are
being achieved and indicators focused on specific improvement activities.
Performance Activities
The performance measurement process is one part of the evaluation of the effectiveness of the Utility
Systems management program. Performance measures have been established to measure at least one
important aspect of the Utility Systems program.
Annual Evaluation of the Utility Management Plan
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The Manager of Plant Operations evaluates the plan annually and submits their findings to the EOC
committee for review. The EOC committee reviews, comments on and approves the report.

Objectives
The evaluation process examines the objectives of the plan to see if objectives:
a.
Were appropriately defined to monitor the effectiveness of the plan.
b.
Measurable
c.
Were achieved
d.
Need to be revised
Scope
The evaluation process examines the scope of the plan to see if there have been changes in the scope that
would require changes in the management plan.
Performance
The evaluation process examines the performance of the plan to see if:
a.
The objectives were met, as measured by the key indicators.
b.
The performance improvement activity targets were met, as measure by the focused
performance improvement Indicator.
Effectiveness
The evaluation process examines the effectiveness of the plan based on the whether or not the objectives and
the performance improvement activity targets were met.
PATIENT SAFETY
The Safety Manager is responsible for working with the individuals responsible for patient safety to integrate
Environment of Care monitoring and response activities into the patient safety program. The integration
includes conducting risk assessments to identify environmental threats to patient safety, conducting
environmental rounds to evaluate patient safety concerns on an ongoing basis, participating in the analysis of
patient safety incidents, participating in the development of material for general and job-related orientation
and on-going education.
THE ORGANIZATION ANALYZED IDENTIFIED EC ISSUES AND DEVELOPS
RECOMMENDATIONS FOR RESOLVING THEM
Providence St. Josephs Hospital Environment of Care Committee
The multidisciplinary EOC Committee meets regularly, at least bimonthly, to consider Environment of Care
issues
Management of Environment of Care Information
Managers of each Environment of Care function, the EOC Committee and department managers collaborate
to analyze Environment of Care issues. The analysis includes ongoing analysis of performance and
aggregate analysis of environmental rounds, incident reports, maintenance activities, and other issues.
The analysis is used to manage the stability of current programs, assess risks related to new programs, and to
identify opportunities for improvement.
Reporting of Environment of Care Activities
Managers of each Environment of Care functions are responsible for Identifying important measures of
environmental or patient safety or of program management. The measures are used to evaluate performance
on an ongoing basis to measure the success of implementation of performance improvement activities and to
develop an understanding of processes that are not meeting expectations.
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Communication with Leadership

Minutes and relevant supporting materials are communicated to all Environment of Care and organization
leaders.
Identification of Performance Improvement Opportunities
When Environment of Care Manager and the EOC committee identify performance improvement
opportunities, a proposal for improvement is prepared and sent to leadership. The leadership reviews all
improvement proposals and determines the priority and need for the proposed improvement.