Draft Details
- Operation and maintenance of health care facil...
- Draft Standard
- Preface
- 0 Introduction
- + 1 Scope
- 1.1 Requirements for operation and maintenance ...
- 1.2 Establishing requirements for HCFs
- 1.3 Organization and coordination with other de...
- 1.4 O&M of patient care equipment and interface...
- 1.5 Non-assignment of responsibilities to speci...
- 1.6 Exclusions
- 1.7 Interpretation of terms and annex designati...
- 2 Reference publications
- + 3 Definitions and abbreviations
- 3.1 Definitions
- 3.2 Abbreviations
- + 4 General requirements
- + 4.1 Management responsibility
- 4.1.1 General
- + 4.1.2 HCF management qualifications
- 4.1.2.1 Management of health care facilities by...
- 4.1.2.2 Ensuring HCF managers' knowledge and sk...
- 4.1.2.3 Certification and professional developm...
- 4.1.2.4 Effective leadership program
- + 4.1.3 HCF owner responsibilities
- 4.1.3.1 Owner's responsibility for operation an...
- 4.1.3.2 Owner responsibilities for health care ...
- 4.1.3.3 Subcontracting and assignment of O&M pr...
- 4.1.4 Contractor qualifications
- 4.1.5 Contractor responsibilities
- + 4.2 Coordinated operation and maintenance progr...
- + 4.2.1 General
- 4.2.1.1 COMP development and implementation
- 4.2.1.2 Responsibility and qualifications for C...
- 4.2.1.3 Identification and responsibilities of ...
- 4.2.1.4 Outline of HCF's policies and objective...
- 4.2.1.5 Staff qualifications, training, and ori...
- 4.2.1.6 Supporting OASIS principles for HCFs th...
- 4.2.1.7 Maintenance and risk management approac...
- 4.2.1.8 Preventive maintenance programs for saf...
- 4.2.1.9 Identification and specification of ext...
- + 4.2.1.10 Energy Management Plan
- 4.2.1.10.1 Energy and emissions targets
- + 4.2.1.10.2 Asset management plan
- 4.2.2.1 Documentation for operations, maintenan...
- 4.2.2.2 Inclusion of testing protocols and docu...
- 4.2.2.3 Addressing manufacturer's instructions ...
- 4.2.2.4 Requirements for health care facilities...
- 4.2.2.5 Maintaining access to current versions ...
- 4.2.2.6 Accessibility and updating of standards...
- 4.2.2.7 Maintenance and renewal of operational ...
- + 4.2.3 Integration with HCF policies, procedures...
- 4.2.3.1 Consistency with HCF policies and proce...
- 4.2.3.2 Prioritizing O&M activities for life sa...
- 4.2.3.3 Specification of critical areas and saf...
- + 4.2.4 Integration of O&M with other services...
- 4.2.4.1 Development and maintenance of cross-de...
- 4.2.4.2 Reference to HCF energy management plan...
- 4.2.4.3 Division of responsibilities and commun...
- 4.2.4.4 Provisions for communication, coordinat...
- 4.2.4.5 Maintenance activities and responsibili...
- 4.2.5 Contract relationships
- 4.2.6 Rented or leased facilities
- + 4.2.7 Maintenance of the COMP
- 4.2.7.1 Review and update
- 4.2.7.2 Periodic review and audit of subsidiary...
- + 4.3 Operation and maintenance procedures
- + 4.3.1 General
- 4.3.1.1 Guidelines for O&M procedures in HCF...
- 4.3.1.2 Periodic review of operational procedur...
- 4.3.1.3 Establishment of work prioritization sy...
- + 4.3.2 Patient and staff safety
- 4.3.2.1 Predictive maintenance procedures for i...
- 4.3.2.2 Monitoring procedures and response to a...
- + 4.3.3 Related services
- 4.3.3.1 Procedures and systems for communicatio...
- 4.3.3.2 Interdepartmental interactions
- 4.3.3.3 Establishment of communication procedur...
- + 4.3.4 Contingency plans
- 4.3.4.1 Contingency plans integration with emer...
- 4.3.4.2 Provisions for situations with uncertai...
- 4.3.4.3 Priority of maintenance activities for ...
- 4.3.5 Rented, leased, and newly acquired buildi...
- + 4.3.5.1 Initial surveys and assessments
- 4.3.5.1.1 Evaluation and improvement of energy ...
- 4.3.5.2 Occupancy requirements
- + 4.4 Risk management
- 4.4.1 Risk assessment for O&M service responsib...
- 4.4.2 Standard approach to risk management
- + 4.5 Inventory
- 4.5.1 Essential components and critical spares
- 4.5.2 Off-site inventory access and emergency c...
- 4.5.3 Procedure for review of on-site storage a...
- + 4.6 Staffing qualifications
- + 4.6.1 General
- 4.6.1.1 Qualification requirements
- 4.6.1.2 Training requirements
- 4.6.1.3 Defining necessary skills, training, an...
- 4.6.1.4 Compliance with personnel certification...
- 4.6.1.5 Requirements for training and qualifica...
- 4.6.1.6 Restrictions on unqualified personnel p...
- 4.6.1.7 Documentation and maintenance
- 4.6.1.8 Frequency of training and evaluation sp...
- + 4.6.2 Education and training
- 4.6.2.1 Documentation requirements
- 4.6.2.2 Staff training and education on energy ...
- 4.6.2.3 Preparation of training documentation o...
- 4.6.2.4 Training programs for operating and mai...
- 4.6.2.5 Education and training for O&M personne...
- 4.6.2.6 Training documentation for infection pr...
- 4.6.2.7 Annual infection prevention and control...
- 4.6.2.8 Infection prevention and control traini...
- 4.6.2.9 Occupational health and safety training...
- 4.6.2.10 Support for ongoing education and trai...
- 4.6.2.11 Preference for recognized institutions...
- 4.6.2.12 Ensuring maintenance and operational r...
- 4.6.2.13 Establishing environmental sustainabil...
- + 4.6.3 Orientation
- 4.6.3.1 Orientation requirements for new employ...
- 4.6.3.2 Staff training and orientation for equi...
- 4.6.3.3 Orientation and refreshment of HCF equi...
- + 4.6.4 Maintenance of qualifications
- 4.6.4.1 Assessment and training of safe operati...
- 4.6.4.2 Annual review and evaluation of O&M per...
- + 4.7 Health and safety
- 4.7.1 Occupational health and safety compliance...
- 4.7.2 Establishment of safety guidelines for fa...
- 4.7.3 Compliance with occupational health and s...
- + 4.8 Outsourcing of services
- 4.8.1 Specialized technical service and mainten...
- 4.8.2 Contractor compliance with organizational...
- 4.8.3 Contractor work authorization and complia...
- 4.8.4 Management of external contractors and tr...
- 4.8.5 Orientation for contracted personnel
- 4.8.6 Secondary training on project-specific or...
- + 4.8.7 Contractor documentation requirements for...
- 4.8.7.1 Monitoring and communication of changes...
- 4.8.9 Work site inspection procedure for contra...
- + 4.9 Quality system
- 4.9.1 Coordinated operation and maintenance pro...
- 4.9.2 Requirements and implementation
- 4.9.3 Documentation and organizational structur...
- 4.9.4 Specifying staff responsibility and autho...
- 4.9.5 Description of significant processes and ...
- 4.9.6 Annual assessment of procedures
- 4.9.7 Identification and correction of deviatio...
- 4.9.8 Auditing of O&M systems
- 4.9.9 Use of external audits for system evaluat...
- 4.9.10 Authority and documentation for internal...
- 4.9.11 Review of operating procedure in respons...
- 4.9.12 Supervision and control of subsidiary fa...
- + 4.10 Documentation and records
- 4.10.1 System for storage and maintenance
- 4.10.2 Policy for retention of records
- 4.10.3 Policy for control of quality systems do...
- 4.10.4 Design and organization of documentation...
- + 5 Building and site maintenance plan
- + 5.1 General
- 5.1.1 Development and maintenance
- 5.1.2 Requirements
- 5.1.3 Consistency with applicable requirements
- 5.1.4 Documentation
- 5.1.5 Work order procedures
- 5.1.6 Compliance testing for medical procedure ...
- 5.1.7 Environmental conditions monitoring and r...
- 5.1.8 Safety and security requirements
- 5.1.9 Monitoring of lighting and safety systems...
- + 5.2 Testing and inspections
- 5.2.1 Building and site maintenance plan specif...
- 5.2.2 Frequency of testing and inspection
- 5.2.3 Testing and documentation of relative pre...
- 5.2.4 Building and site maintenance plan protoc...
- + 5.3 Building envelope
- 5.3.1 Maintenance of building envelope for HVAC...
- 5.3.2 Identification and repair of extreme heat...
- 5.3.3 Maintenance and inspection of louvred ent...
- 5.3.4 Inspection of entry doors, windows, sunsh...
- + 5.4 Interior separation
- 5.4.1 Monitoring and maintaining interior space...
- 5.4.2 Monitoring and maintenance of building el...
- + 6 Systems operation manuals and maintenance and...
- + 6.1 General
- 6.1.1 Requirements
- 6.1.2 Integration testing for complex systems i...
- 6.1.3 Integration testing for interrelated syst...
- 6.1.4 Systems operation manuals requirements
- 6.1.5 Maintenance and data manuals provisions
- 6.1.6 Structuring and organizing operation, mai...
- 6.1.7 Obtaining and producing updated manuals a...
- 6.1.8 Requirement for manuals and as-built draw...
- 6.1.9 Reference to standards and guidelines in ...
- 6.1.10 Development and cross-referencing of man...
- 6.1.11 Maintaining current manuals and drawings...
- + 6.2 Systems operation manuals
- 6.2.1 Requirements for systems operation manual...
- 6.2.2 Systems operation manual requirements
- 6.2.3 Organization of systems operation manuals...
- 6.2.4 Operational activity logging in systems o...
- 6.2.5 Modifications to sequences of operation a...
- + 6.3 Maintenance and data manuals
- + 6.3.1 General
- 6.3.1.1 Obtaining maintenance and data manuals ...
- 6.3.1.2 Up-to-date maintenance and data manuals...
- 6.3.1.3 Organization of maintenance and data ma...
- 6.3.1.4 System schematic and component informat...
- 6.3.1.5 Inclusion of shop drawings and maintena...
- 6.3.1.6 Special monitoring and testing requirem...
- 6.3.1.7 Reference and procedure for testing pro...
- 6.3.1.8 Consistency of maintenance and data man...
- 6.3.1.9 Integration of manufacturer's manuals i...
- 6.3.1.10 Maintenance and data manuals: problem ...
- + 6.3.2 Equipment and systems
- 6.3.2.1 Maintenance procedures and risk assessm...
- 6.3.2.2 Requirements for maintenance and data m...
- 6.3.2.3 Verification and testing documentation ...
- 6.3.2.4 Database maintenance program for equipm...
- 6.3.2.5 Maintenance of process equipment
- 6.3.2.6 Defining responsibilities for process e...
- 6.3.2.7 Process equipment listing and maintenan...
- 6.3.2.8 Equipment and systems testing and inspe...
- 6.3.2.9 Inspection and testing of medical gas s...
- 6.3.2.10 Inspection and testing of emergency po...
- 6.3.2.11 Duct cleaning procedure compliance
- 6.3.2.12 Cleaning of cooling towers
- 6.3.2.13 Maintenance of patient lifts and hoist...
- 6.3.3 Integrated systems and functions
- 6.3.4 Site and building elements
- + 6.3.5 Technology-critical clinical spaces
- 6.3.5.1 Troubleshooting procedures for equipmen...
- 6.3.5.2 Maintenance and data manuals for techno...
- + 6.3.6 Automated control systems
- 6.3.6.1 Development and testing
- 6.3.6.2 Verification of control system integrat...
- + 6.3.7 Medical procedure rooms
- 6.3.7.1 Maintenance and testing procedures
- 6.3.7.2 Verification and maintenance of air cha...
- 6.3.7.3 Verification of air changes in medical ...
- 6.3.7.4 Periodic testing frequency and building...
- 6.3.7.5 Compliance requirements for relative pr...
- 6.3.7.6 Verification and calibration of pressur...
- 6.3.7.7 Building and site maintenance plan spec...
- 6.3.7.8 Verification of essential operating cha...
- 6.3.7.9 Continuous monitoring and daily checks ...
- 6.3.7.10 Fume hood testing and certification re...
- 6.3.7.11 Testing of laboratory air-handling sys...
- 6.3.7.12 Verification of minimum outside air se...
- + 6.3.8 Work orders and maintenance management sy...
- 6.3.8.1 Generating work orders for equipment or...
- 6.3.8.2 Maintenance work orders for life-safety...
- 6.3.8.3 Requirements for maintenance work order...
- 6.3.8.4 Maintenance management system requireme...
- 6.3.8.5 Automated systems for work order genera...
- 6.3.8.6 Integration of automated systems for wo...
- + 7 Emergency and continuity response plans
- 7.1 Emergency and continuity management program...
- 7.2 Establishment of emergency and continuity m...
- 7.3 Emergency and continuity management program...
- 7.4 Emergency and continuity response plans in ...
- 7.5 Emergency and continuity response plan cons...
- 7.6 Emergency and continuity response plan deve...
- 7.7 Emergency and continuity response plans int...
- 7.8 Emergency and continuity response plans for...
- 7.9 Standardized approach to incident managemen...
- 7.10 Emergency and continuity response plans de...
- 7.11 Procedures for recovery of normal operatio...
- 7.12 Post-emergency procedures and recovery pla...
- + 8 Commissioning, recommissioning, monitoring, a...
- + 8.1 General
- 8.1.1 Commissioning requirements and schedules
- 8.1.2 Use and creation of commissioning documen...
- 8.1.3 Development of monitoring program and ret...
- + 8.1.4 Commissioning and training for new equipm...
- 8.1.4.1 Commissioning of new equipment/systems
- 8.1.4.2 Education and training in new equipment...
- 8.1.4.3 New equipment/systems training requirem...
- 8.1.4.4 New equipment/systems training delivery...
- 8.1.4.5 Digital recording of new equipment/syst...
- + 8.2 Facility optimization
- 8.2.1 Resource optimization and cost control
- 8.2.2 Optimization elements
- 8.2.3 Development of energy-management plan
- 8.2.4 Energy management and continuous monitori...
- 8.2.5 Management and control of utilities
- 8.2.6 Building automation system monitoring and...
- 8.2.7 Monitoring and analysis of non-automated ...
- 8.2.8 Performance analysis
- 8.3 Recommissioning
- + 9 Annual reporting
- 9.1 Annual reporting on HCF operation and maint...
- 9.2 Annual report preparation based on monitori...
- 9.3 Annual report requirements for HCF's infras...
- + 9.4 GHG emission and energy use reporting
- 9.4.1 Sustainability
- Annex A (informative)
- + Annex B (informative)
- B.1 Access to information and instructions for ...
- + Annex C (informative)
- C.1 Special monitoring and testing requirements...
- + Annex D (informative)
- D.1 Quality system management in institutions
- + Annex E (informative)
- + E.1 General
- E.1.1 Maintenance and periodic testing of opera...
- E.1.2 Determining ventilation parameters compli...
- E.1.3 Testing and monitoring by qualified O&M p...
- + E.2 Test procedure
- E.2.1 Procedure for testing room seals and air ...
- E.2.2 Independent measurement of differential p...
- E.2.3 Comparison and calibration of pressure-se...
- E.2.4 Additional testing procedures for airborn...
- E.2.5 Verification procedure for redundant exha...
- E.2.6 Recording of test results
- + Annex F (informative)
- + F.1 General
- F.1.1 Airflow control and maintenance in specia...
- F.1.2 Determination of ventilation parameters b...
- F.1.3 Testing by trained personnel and building...
- + F.2 Test procedure
- F.2.1 Procedure for testing room seals and air ...
- F.2.2 Measurement of differential pressure usin...
- F.2.3 Comparison and calibration of pressure-se...
- + Annex G (informative)
- + G.1 General
- G.1.1 Testing air change rates in airborne isol...
- G.1.2 Verification of air change rates
- G.2 Test participants
- + G.3 Test procedure
- G.3.1 Procedure for airborne isolation room tes...
- G.3.2 Recording test results for airborne isola...
- + Annex H (informative)
- + H.1 General
- H.1.1 Testing frequency for air-handling units ...
- H.1.2 Verification of minimum outside air chang...
- H.2 Test participants
- + H.3 Test procedure
- H.3.1 Procedure for testing and recording resul...
- H.3.2 Adjustment of damper positions and test r...
- H.3.3 Comparison and calibration of independent...
- H.3.4 Recording of test results
- + Annex I (informative)
- + I.1 Classification of O&M personnel
- I.1.1 Defining roles of O&M personnel based on ...
- I.1.2 Classification of personnel in facility o...
- I.1.3 Qualifications for defined roles
- I.2 Building operators
- I.3 Maintenance personnel
- I.4 Technicians or skilled trades
- I.5 Users
- + I.6 HCF manager responsibilities and qualificat...
- I.6.1 Management of HCFs by competent individua...
- I.6.2 Professional development requirements for...
- I.6.3 Primary job responsibilities of HCF manag...
- + I.6.4 Responsibilities of the HCF manager
- I.6.4.1 Maintenance and operations
- I.6.4.2 Code compliance
- I.6.4.3 Planning, design, and construction
- I.6.4.4 Finance management
- I.6.4.5 Administration
- + Annex J (informative)
- J.1 Purpose of a MMS
- J.2 Opening a work order
- J.3 MMS system options
- J.4 MMS considerations for an O&M service
- J.5 Closing a work order
- J.6 Key features of a computerized MMS
- + J.7 Data collection and systems integration for...
- J.7.1 Use of building information modelling sof...
- J.7.2 Information gathering from BIM software
- J.7.3 Integration of information systems in fac...
- J.7.4 Online access to systems and database inf...
- + J.8 BIM/CMMS integration
- J.8.1 Overview
- J.8.2 Pre-design
- J.8.3 Design
- J.8.4 Tendering
- J.8.5 Construction
- J.8.6 Commissioning
- J.8.7 Turnover
- + Annex K (informative)
- K.1 General
- + K.2 Program topics
- K.2.1 Introduction
- K.2.2 General guidelines and information
- K.2.3 Responsibilities and requirements
- K.2.4 Incident/near miss reporting
- K.2.5 Fire safety
- K.2.6 Chemical safety
- K.2.7 Workplace violence, bullying and harassme...
- K.2.8 Infection control
- K.2.9 Security
- K.2.10 Appendices
- + Annex L (informative)
- L.1 General
- L.2 Basic orientation
- + L.3 Department orientation
- L.3.1 Introduction to department
- L.3.2 Personnel requirements
- L.4 Safety and security
- L.5 Waste management
- L.6 Miscellaneous
- L.7 Plant and support services
1.1 Requirements for operation and maintenance of HCFs
This Standard describes the requirements, including quality system requirements, for the O&M of a HCF. It sets out specific requirements for
a) facility architectural systems;
b) exterior site elements related to the building and its functions;
c) utilities;
d) the facility’s infrastructure, including but not limited to mechanical, electrical, and information management and information technology, and security systems;
e) health care equipment;
f) life safety systems;
g) specialized functional programs, including but not limited to ORs, MDR, pharmacy, and laboratories;
h) permanently installed equipment as specified in Clause 1.4;
i) building services and interfaces for installed equipment, both medical and non-medical; and
j) best practices for sustainability, resilience, energy conservation, decarbonization and adaptation to climate change
Note: The HCF should be aware of federal, provincial/territorial, and municipal regulatory requirements applying to O&M and life safety systems, in addition to relevant CSA Group standards.
1.2 Establishing requirements for HCFs
This Standard establishes requirements for the HCF as a whole.
Note: HCFs vary widely in size, scope, and organization. This Standard sets out the essential O&M requirements for an HCF: it is expected that the HCF will develop the appropriate administrative structures and reporting relationships.
1.3 Organization and coordination with other departments in O&M activities
This Standard addresses the organization of, and the policies and procedures regarding other departments as they relate to O&M activities. It also includes requirements for the necessary coordination of O&M activities with other related HCF departments and functions.
Note: Examples of other departments and functions include security, biomedical engineering, environmental services, housekeeping, and nursing.
1.4 O&M of patient care equipment and interfaces
This Standard addresses the operation and maintenance of permanently installed equipment used to support patient care (e.g., call systems, human waste disposal units). It also includes requirements for the O&M of interfaces between equipment and building systems (e.g., equipment docking and charging stations).
Notes:
1) There is not always a clear line between the services and interfaces that support clinical equipment [see Clause 1.1, Item g)], and the clinical equipment itself. At a minimum, interfaces include physical space requirements and the use of utilities; however, there can be other connections (e.g., mechanical, electrical, computerization, telemetry, etc.). Problems can arise when different departments of the HCF each assume that the other is looking after a particular system. Among the tasks involved in planning an O&M program are to determine where the divisions are and then to document who is responsible for the different elements of the system.
2) In smaller facilities, O&M personnel or a department could have responsibility for equipment maintenance beyond the scope of this Standard. In that case, the person or department responsible for O&M should develop the appropriate expertise and consult relevant standards for these expanded duties (e.g., standards for biomedical engineering).
1.5 Non-assignment of responsibilities to specific job titles or departments
This Standard does not assign responsibilities to specific job titles or departments.
1.6 Exclusions
This Standard does not address the operation and maintenance of clinical equipment used for life support or therapeutic purposes (e.g., infusion pumps, anaesthetic workstations, and MRI machines).
1.7 Interpretation of terms and annex designation
In this Standard, “shall” is used to express a requirement, i.e., a provision that the user is obliged to satisfy in order to comply with the standard; “should” is used to express a recommendation or that which is advised but not required; and “may” is used to express an option or that which is permissible within the limits of the standard.
Notes accompanying clauses do not include requirements or alternative requirements; the purpose of a note accompanying a clause is to separate from the text explanatory or informative material.
Notes to tables and figures are considered part of the table or figure and may be written as requirements.
Annexes are designated normative (mandatory) or informative (nonmandatory) to define their application.
You may comment on any section of this document by clicking the “Submit Comment” link at the bottom of the relevant section.