Welcome to Lander Regional Hospital

Utility Management Performance Plan

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I. POLICY
A. The board of trustees strives to assure that the hospital is functionally safe and maintains a sanitary health care environment for patients of all ages, visitors, employees, volunteers, and medical staff by requiring and supporting the establishment and maintenance of an effective utility management program.

B. The hospital shall comply with all current occupational, health, safety, and environmental laws and develop the most appropriate operations, procedures, and policies to provide such conditions.

II. SCOPE, GOALS, AND OBJECTIVES
A. The purpose and scope of the utility management plan is to outline the process that supports the hospital's mission and vision statements by providing a safe, comfortable, dignified, positive and private environment for patients and visitors as well as a safe work environment for employees, volunteers and medical staff.

B. The utility management program is planned to promote and support optimal patient care through effective evaluation and improvement of important processes, systems, and outcomes of patient care provided by all disciplines within the organization.

C. The utility management program gives high priority to:

1. Establishing written criteria to identify, evaluate, and inventory critical operating components of utility systems to be included in the utility management program, which includes:

a. Life support systems;
b. Infection control systems;
c. Environmental support systems;
d. Equipment support systems; and
e. Communication systems.

2. Assessing risks to ensure operational reliability associated with utility systems through inspection, testing, and maintenance or critical operating components and the education of users and maintainers of the systems;

3. Maintain current utility system:

a. Operational plans that are written to help ensure reliability, minimize risks, and reduce failures; and
b. Labeling of controls for a partial or complete emergency shutdown of each utility system.

4. Identifying distribution of each utility system for a partial or complete emergency shutdown.

5. Reporting and investigating utility systems management program problems, failures, or user errors that are or may be a threat to the patient care environment.

6. A current, accurate, and separate inventory of all utility components in the utility management program.

7. Preventative maintenance and inspection of utilities systems.

8. Maintenance and operational measures to prevent and remove microbial contamination in utility systems susceptible to water borne infectious diseases such a Legionellosis, Pontiatic fever, and other water borne diseases such as E Coli and salmonella,

9. Inspecting, testing, and maintaining of critical operating components e.g. emergency generator.

D. Emergency procedures for system disruptions and/or failures:

1. Addresses specific procedures for failure and/or disruption;
2. Alternate source(s) for essential utilities;
3. Operating procedures for shut-off controls including who authorizes and receives report of action.
4. Procedures for obtaining repair services; and
5. Need and method for emergency clinical interventions.

E. Maintain current, complete set of documents that indicate the distribution of each utility system, including controls for a partial or complete shutdown.

F. Provide a source of emergency power system:

1. That is appropriately sized, correctly designed, properly installed, and has an adequate fuel source.

2. To number of systems/equipment during normal power
interruptions as per NFPA 99 guidelines.

3. Demonstrates functional and reliable emergency power system by conducting test of each generator using loads other than Essential Electrical System load for generator testing purposes.

G. The program provides and integrated and coordinated effort toward life safety, risk, and safety management which complies with Wyoming statutes, meets Joint Commission on Accreditation of Healthcare Organizations (JCAHO), National Fire and Protection Association (NFPA), Life Safety Code 2000 (LSC), and Occupational Safety and Health Administration (OSHA) standards and assists our facility in controlling losses related to professional and general liability.

III. PERFORMANCE STANDARDS
A. The utility management program works in conjunction with quality, risk, and safety management to assist other departments in establishing, implementing, monitoring, and documenting evidence of ongoing organization-wide performance measurement.

B. This program is integrated into the hospital's overall effort to assess and improve its performance standards.

C. Hospital staff, within their area of responsibility, will be able to demonstrate or describe:

1. Their knowledge and skill requirements, capabilities, limitations, special applications and/or maintenance, in the utility management program and expected level of performance;

2. Proper emergency procedures or clinical interventions if a utility failure or disruption occurs;

3. Organization's occurrence reporting system for events that involve utility system issues or events;

4. Routine monitoring and inspections activities, preventative maintenance, and testing of utility equipment; and

5. Actions to prevent, eliminate, minimize or report utility or safety risks.

D. Hospital staff's knowledge of policies, procedures and responsibilities under the program are assessed:

1. Following each educational session by a competency examination and/or observation/demonstration.

2. Through oral questioning during routinely scheduled loss prevention and safety survey that ensures complete coverage of the facility's buildings and structures at least annually.

E. Director of plant operations and department directors can describe their role in developing departmental and organizational policies and procedures to include examples of the utility management program's goals and performance standards.

F. Selected utility system equipment is inspected, provided preventative maintenance and tested at regular intervals to ensure operation and operator familiarity.

IV. EDUCATION, ORIENTATION AND TRAINING
A. Utility system training is provided at orientation and annually thereafter to all employees and volunteers.

B. The structured staff development program includes general practices, capabilities, limitations, special applications, emergency procedures for failure/disruption, information and skills necessary to perform maintenance responsibilities, location of emergency shut-off controls,
and supplemented by organizational experience.

C. Occurrence report training is provided at orientation and annually thereafter to all employees and volunteers.

D. Each employee is provided department and job-specific-related life safety training that includes clinical intervention and emergency procedures if a utility system fails or disruption occurs and is documented in his/her individual educational file.

V. INCIDENT REPORTING
A. Any occurrence out of the ordinary which results in a potential for or actual injury to a patient, visitor, employee, volunteer, or medical staff member, or damage to the facility property or public reputation, will be reported through completion of an incident report.

B. Report must be completed within twenty-four hours of the discovery or event, followed by supervisor and/or department director's review prior to forwarding to the director of risk management/designee within seventy-two hours.

VI. ROLES AND RESPONSIBILITIES
A. Director of Plant Operations:
1. Establishes written criteria to identify, evaluate, and inventory critical operating components of utility systems included in the utility management program;

2. Assess risks to ensure operational reliability associated with utility systems through inspection, testing, and maintenance of critical operating components and the education of users and maintainers of the systems;

3. Maintains current utility system:

a. Operational plans that are written to help ensure reliability, minimize risks, and reduce failures; and
b. Labeling of controls for a partial or complete emergency shutdown of each utility system;

4. Identifies distribution of each utility system for a partial or complete emergency shutdown.

5. Reports and investigates utility systems problems, failures, or user errors that are or may be a threat to patient care environment.

6. Establishes emergency procedures for utility system disruptions and/or failures:

a. Addresses specific procedures for failure and/or disruption;
b. Alternate source(s) for essential utilities;
c. Operating procedures for shut-off controls including who authorizes and receives report of action.
d. Procedures for obtaining repair services; and
e. Need and method for emergency clinical interventions.

7. Maintain current, complete set of documents that indicate the distribution of each utility system, including controls for a partial or complete shutdown.

8. Provide a source of emergency power system:

a. That is appropriately sized, correctly designed, properly installed, and has an adequate fuel source.

b. That supplies electricity during interruption of normal power to a number of vital systems/equipment as per NFPA 99.

9. Demonstrates functional and reliable emergency power system by conducting test of each generator using loads other than Essential Electrical System load for generator testing purposes.

B. Each Employee:

1. Demonstrates the knowledge and skills necessary to satisfactorily perform the tasks assigned to his/her position in support of the utility management programs.

2. Understands and follows the proper emergency procedures if utility failure or disruption occurs.

3. Adheres to the organization's incident reporting system for events that involve utility system issues or events.

4. Plant Operations Technician- Performs routine monitoring and inspections activities, preventative maintenance, and testing of utility systems/equipment, and

5. Takes appropriate action to prevent, eliminate, minimize, and report utility or safety risks.

C. Environment of Care Committee:

1. Receive and investigate reports and take action, as appropriate, on all incidents and/or utility systems reports.

2. Review and revise, as necessary, all utility system policies and procedures, both department and hospital-wide at least every three years and assure that these policies and procedures are distributed, practiced and enforced.

3. Provide quarterly reports to the board of trustees, administration and quality council.

VII. ANNUAL EVALUATION
The Environment of Care Committee shall conduct an annual evaluation of the objectives, scope, performance, and effectiveness of the utility management program with revisions made, as necessary, based upon organizational experience, applicable laws and regulation(s) and accepted practice.

US Patent Numbers 7,720,998 B2, 7,836,207