STANDARD:4

FMS:1
 The Hospital is aware of and complies with
the relevant laws, rules, regulations,
bylaws and relevant building / associated
codes applicable to hospitals.

(Ind. 12-13)

Prepared by ____________ Approved by: _____________

 Ind.12
The management is conversant with the
relevant laws and regulations
Health Related Legislations

Sr.# Health Related Laws Link to Download

1. 2012 Amendment in the PM&DC [Link]
Ordinance fileticket=a8Uzv7NVyX4%3D&tabid=292&mid=850
2. Drug Regulatory Act, 2012 [Link]
1352964021_588.pdf
3. Pakistan nuclear Regulatory act. PNRA Google search
4. The Punjab Food Authority Act,2011 [Link]
5. The Punjab Healthcare Commission [Link]
Act, 2010
6. The Punjab Consumer Protection Act, [Link]
2005
7. Injured Persons (Medical Aid) Act, [Link]
2004 (XII Of 2004) %20PERSONS%20(%20MEDICAL%20AID%20)%20ACT,
%[Link]
8. The Punjab Blood Transfusion Safety [Link]
Act 2016 (Act Xlvi Of 2016)
9. The Punjab Environmental Protection [Link]
Act, 1997 amended in 2009
10. The Punjab Health Foundation Act, [Link]
1992
11. Drug Rules, 1986 [Link]
fileticket=2tywGfuonwM%3D&tabid=102&mid=588
 12. Drug Labeling & Packaging Rules, [Link]
1986
13. Drugs Act, 1976 [Link]
q=aHR0cDovLzE5Mi4xNjguNzAuMTM2L2RyYXAvdXNlcmZpbG
VzMS9maWxlL2RvY3MvVGhlRHJ1Z3NBY3QxOTc2LnBkZg%3D
%3D
14. The Pakistan Nursing Council Act, [Link]
1973 %20PAKISTAN%20NURSING%20COUNCIL%20ACT,
%[Link]
15. Pharmacy Act, 1967 [Link]
fileticket=j9LEQikCYbs%3D&tabid=102&mid=588
16. Provincial Employees Social Security [Link]
Ordinance, 1965
17. The Hazardous Occupations Rules, [Link]
1963 %20PAKISTAN%20HAZARDOUS%20OCCUPATIONS%20(LEAD)
%20RULES,%[Link]
18. The Epidemic Diseases Act, 1958 [Link]

19. The Public Health (Emergency [Link]

Provisions ) Ordinance, 1944
20. Punjab Hospital Waste Management Google search
Rules 2014
21. THE PUNJAB HEPATITIS ACT 2018 (Act [Link]
XII of 2018)
22. Punjab medical faculty Act Google search
S
UP DATED LAWS

Sr.# Health Related Laws Link to Download

23. PMC Act 2020 [Link]
fileticket=a8Uzv7NVyX4%3D&tabid=292&mid=850
24. Infectious disease act. [Link]
1352964021_588.pdf
25. PHC Inspection rules & regulations Google search
 2020

List of Laws Applicable to Al Shifa Surgical Hospital

 The Civil Defence Rules 1951

 Drug Labeling and Packing Rules 1986
 Injured Person Rule 2014
 PHC act 2010
 PMDC act 2019
 PMDC code of Ethics
 PNC Act 1973
 Drug regulatory Act 2012
 Punjab Reproductive, Maternal Neonatal and Child Health
 Consumer Protection Act 2005
 Punjab Blood Transfusion Safety Act 2016
 Hospital Waste Management Act 2014
 Punjab Environment Act 2012
 Building Safety Codes
 Fire Safety Codes
 Ind. 13
The licenses / registrations / certifications are
current and there is a mechanism to regularly
update the same.
 Standard 5. FMS-2:
The hospital/HCE has a program for
management of equipment for clinical and
support services.

(Ind. 14-16)

Prepared by __________ Approved by: ___________

 Ind. 14.
The hospital/HCE has equipment in
accordance with the scope of its services.
List of Electro medical Equipments
Name of Equipments
Anesthesia Machines
OT Table
OT Light Celing
Portable OT lights
Gass Supply O2
NO2
Suckers
Cautery
Crash Cart Trollys
Delivery Beds
ECG Machine
BP Appratus
Weight Machines
Glucometers
AutoCalaves
Generators
Cardiac Moniter
USG Machine
CBC Analyzer
Baby incubator
Baby warmer
 Al Shifa Surgical Hospital

NOTIFICATION

The following officials of Al Shifa Surgical Hospital is hereby notified as member of purchase
committee/ write off committee. Detail as below:

Dr. Rizwan Anwar Chief Executive Officer

Hussnain Member `
[Link] Yousaf Member
M Rashid Admin

The committee will ensure implementation of purchase/condemnation SOPs.

Chief Executive Officer

 Equipment Procurement Plan

1. Acquisition:
Before purchasing any equipment, demand is collected from each section of the
hospital. The hospital committee after prioritizing of demand, decides about the
equipment to be purchased.
Committee decides about specifications of equipment. Equipment is purchased
according to specifications decided, at proper cost
2. Testing:
When the equipment is received at hospital, it is ensured that the supplying firm
installs and gives installation and testing report of the equipment.
3. PPM (planned preventive maintenance):
For maintenance of the equipment, the firm supplying the equipment is responsible for
its maintenance during the warranty period.
After expiry of the warranty period, fresh contracts will be made with reputable firms
for proper and timely maintenance of the equipment.
The maintenance schedule is obtained from the firm and record of inspection reports is
maintained.
Training of the staff operating the equipment is ensured
4. A list of all inventories is maintained along with history sheet of each equipment and
log book.
5. Repair of each equipment when required is carried out timely.
Electro medical equipment List and Schedule Maintenance Plan
 Ind. 15
Qualified / trained personnel operate and
maintain the equipment.
 Ind.16
Each regular / part time employee is
appropriately oriented to the relevant
section / service policies and procedures as
well as his /her responsibilities, rights and
patients’ rights and responsibilities
 AL SHIFA SURGICAL HOSPITAL

Log Book
Equipment Maintenance/Service & Repair Record
Name of Equipment. _______________________ Item #

Sr.# Department Scheduled Date of Schedule Date of Service/ Bio-medical/

Maintenance Maintenance Calibration Calibration Repair technician
due date due date Date Sign & stamp

7
 Standard 6. FMS-3:
The hospital/HCE has plans for fire and non-
fire emergencies within the facilities.

(Ind. 17-20)

Prepared by ____________ Approved by: ___________

 Ind.17
The hospital has provisions for
i. Early detection,
ii. Containment and
iii.
Abatement of fire and non-fire emergencies.
Emergency Plans
The disasters may include:
1. Earthquake
2. Civil disorders effecting the HCE
3. Terrorist attacks
4. Invasion of swarms of insects and pests
5. Invasion of stray animals
6. Hysteric fits of patients and/or relatives
7. Anti-social behavior by patients/relatives
8. Temperamental disorders of staff causing deterioration in patient care
9. Spillage of hazardous (acids, mercury, etc.), infected materials (used gloves,
syringes, tubing, sharps, Etc.) and medical wastes (blood, pus, amniotic fluid,
vomits, etc.)
10. Building or structural collapse
11. Fall or slips or collision of personnel in the corridors
12. Fall of patient from the bed/stretcher
13. Bursting of pipelines
14. Sudden flooding of areas like basements due to clogging in pipelines or heavy rains
15. Sudden breakdown of supply of electricity, gas, vacuum, etc.
16. Bursting of boilers and/or autoclaves
17. Bursting of pipelines
18. Sudden flooding of areas like basements due to clogging in pipelines or heavy rains
19. Sudden breakdown of supply of electricity, gas, vacuum, etc.
 Fire Emergency Plan
Necessary Items and Equipment

Sr, No Items Numbers Installed/placed

1 fire extinguishers 3 Ground,1st ,2nd,3rd
Floor
2 Safety water supply 1 Ground Floor

Actions.

Sr.# Activity Description Floor Responsibilities

1 Intimate the In case of any Ground,1st,2nd,3rd Floor All Employees
fire emergency it is the
emergency core responsibility to
inform the
management and fire
emergency team

2 Evacuation of Ensure all staff and 3rd Floor Tahir Durani,Madhia Umer
staff & patients evacuation
patient from each floor
3 Switch off Switch off main Ground Floor M Rashid
electrical/Gas electric & Gas supply
supply 1st Floor Ahsan Nawaz

2nd Floor M Sulman

3rd Floor M Umer

4 Fire fighting Use firefighting Ground Floor M Rashid

equipment by trained
 staff 1st Floor Ahsan Nawaz

2nd Floor M Sulman

3rd Floor M Umer

5 Call Rescue If uncontrollable call Ground Floor M Rashid
1122/ civil Rescue 1122 or fire
defense brigade
 Fire Evacuation Plan

Sr. # Task Morning Evening Nights

1 Pulling of Alarm/ M Qasim Hameed M Mursleen

Inform Administration
about Fire

2 Team Leader M Rashid M Rashid Hasnain

Closing of Windows Saleem Aslam Mohsin

and Doors
3

4 Instruct Visitors and Ghazala Riaz Khadija BiBi Ahsan Nawaz

Patients

5 Turn off O2 any NO2 Tahir Durani Hameed M Salman

Cylinders

6 Switch off Electricity Tahir Durani Hameed M Salman

7 Call to 1122 M Rashid M Rashid Hasnain

8 Fire Fighting Ahsan Nawaz Salman Umer

9 Round of Hospital M Rashid M Rashid Hasnain

Detection: ‘
All the hospital staff on duty especially security person receptionist ward boys and nurses at
the nursing station ready to notice any smoke, spark or smell in their respective area of duty.
In such case they send one person for help (intimating the management person at once) and
take the appropriate actions like switching off electricity use of fire extinguisher or sand bucket
etc.
Containment:
The team responsible for containment will take a quick review of the situation in order to
assess if they can play their role for the purpose or simply try to initiate the alarm for
evacuation and help abating the fire. General guidelines given below are helpful in carrying out
the containment.
Abatement:
It is very important to decide when to try abatement and when not to. The fire resulting from
short circuit will never be controlled with water unless the power is cut off through main
switch or the circuit breaker. If fire doesn’t seem to be controllable by the hospital internal
resources, it is essential to call help (fire brigade, civil defense) immediately even before
starting the efforts for abatement.

General guidelines
1. When fire is detected, stay calm, try to oversee the situation and watch out for danger.
Then the following actions will be taken in this order:
a. Close windows and doors.
b. Give fire alarm (shouting, telephone, fire alarm).
c. Rescue people (and animals if present).
d. Switch off electricity and/or gas supply.
e. Fight fire, if possible with at least two persons.

2. Persons with clothes burning will be wrapped in a blanket on the floor, sprayed with
water. A CO2 fire extinguisher can also be used, but do not spray on the face.

3. When using fire extinguishers, it is important that the fire is fought at the source of the
fire i.e. at the bottom of the flames, not in the middle of the flames. If gas cylinders are
present, there is the danger of explosion by overheating. If they cannot be removed,
take cover and try to cool them with a fire-hose. When the situation looks hopeless,
evacuate the building. Let everybody assemble outside and check that no one is
missing. To practice this, a regular mock fire drill (once a year), will be held.
Chief Executive Officer
Plan for fire emergencies is comprised of the following:

 Early detection of fire emergencies

 Containment of fire emergencies
 Abatement of fire emergencies

Following persons are responsible and involved in taking the measures to combat with fire
emergencies.
 Housekeeping staff
 Gardeners
 Security staff
 Staff of maintenance division
1. Early Detection
 On detection of the fire (e.g. smoke), the fire alarm will be given in the form of
shouting, Fire! Fire!
 Electricity supply will be switched off
 Doors and windows shall be closed
2. Containment
The trained staff will combat the fire. Door and windows shall be closed. The fire will
be contained by throwing water and sand. Fire extinguishers shall be used. The gas
cylinders if present shall be removed immediately.
3. Abatement
If the situation Detroiters, further staff shall be deployed for throw sand on the fire and
by proper use of fire extinguishers. In case of need, fire brigade / rescue 1122 shall be
called for help.
Following equipment is available for combating fire emergency.
 Sand and water buckets in each section.
 Fire extinguishers
4. Staff has been trained for combating such emergency
 Fire Fighting Protocol
 The first person who detects smoke / fire will report the fire incidence to the telephone
exchange immediately.
 The telephone operator will inform the team leader of firefighting, security supervisor
and housekeeping department immediately.
 Telephone operator will also inform Admin/CEO immediately.
 The firefighting team will comprise of followings:

The firefighting team will comprise of followings:

Team leaders - 03
8 am to 10 pm Morning & Evening
9 pm to 5 am Morning & Evening
8 am to 8 pm Morning & Evening
8 pm to 8am Night

Security Supervisor – 02

8 am to 8 pm Morning
8 pm 8 am Night
Housekeeping Staff – 5

8am to 8pm Morning

8am to 8pm Morning
8pm to 8am Night

OT Staff
8am to 8pm Morning
8am to 8pm Morning
Security guards -01
8 am to 8 pm
8 pm to 8 am

The team leader will be overall In-Charge of the proceedings and will ensure gets
firefighting kits and fire extinguishers are ready to use.

 The firefighting team immediately rush to the fore site to control the fire.
 If the fire is not controlled despite the efforts of the team, team leader will contact the
Rescue 1122 / fire brigade for help.
 Patients evacuated from different areas of the hospital through designated exits
 All designated emergency exits and hospital gates kept clear.
  The female staff of each area carry out consulting of the patient and their attendants to
alleviate their anxiety. Moreover, she also keep complete record of the patients leaving
the hospital.
 A firefighting drill will be conducted on bi-annual bases. Additional CEO will act as
spokesman before media in case of need.

Evacuation (Exit) Plan – Fire Emergencies

Evacuation efforts shall be concentrated upon evacuation of:
 Patients should be shifted immediately to the safe area of the hospital.
 Staff of hospital, Staff members should be evacuated and all of them shall assemble at a
fixed area. Where head – counting of the staff shall be carried out.
 Important equipment
a. Important equipment of hospital and gas cylinders shall be immediately got evacuated.
 Ind.18
The Hospital has a documented safe exit
(evacuation) plan in case of fire and
non-fire emergencies.

EMERGENCY EXIT

Emergency Exit Plan

The has two exits and unobstructed escape routes in case of fire. Fire Exit Signs are posted at
appropriate places. The emergency exits are clearly marked and obstructions must be kept
away from exits at all times. Hospital establish liaison with civil and police authorities, and
Rescue 1122 and the Fire Brigade as required by law for enlisting their help and support in
case of an emergency.
Emergency Exit System
• Lighting source is of reasonably assessed reliability, such as public utility electric
service.
• Emergency lighting facilities maintain the specified degree of illumination in the event
of failure of the normal lighting for a period of at least one hour
• “EXIT” signs
• Size of signs-readable from a distance of 15-20 meters.
• Corridors, hallways and aisles 2.5 meters in width.
• Use of ramps as access to second and higher floors.
 • Stairways with safe and adequately secured railings.

Children:
Children given first priority while evacuation. caried out by their mothers or attendant and if
unattended or the attendant cannot carry the child it will be the responsibility of the duty
nurse to hold the child herself or take help from the ward servants, maids, or even other
patients who are fit for the job. The newborns and the children in incubators or under
warmers shall be carried wrapped in blankets.
Patients:
The patients who can walk guided to the appropriate exit while those who cannot walk
transported through wheelchairs or the stretchers as the situation and the condition of the
patient permits.
Staff:
Staff evacuate in the last however unnecessary lingering must be avoided.
All the persons gather in the assembly area so that a head count can be done. It is necessary
in order to ensure everyone in the building has been successfully evacuated.

Chief Executive Officer

 Ind. 19
Simulation exercise is held at least once in a
year.
Fire Alarm/Fire Drill Report
To be completed after every alarm or drill by designated fire safety officer
Date: ______________________________________ Time: ______________________

Location of Alarm/Fire sign: ________________________________________________

Name of person pulling alarm: ______________________________________________

1) Rounds of hospital made by:

1st Floor: ___________________2nd Floor: _________________ Doors closed: ____________

Hallways Cleared: _________________________________________________________

Visitors/Patients – Instructed Appropriately: ____________________________________

Staff knows how and when to turn off 0 : ______________________________________

2

Fire Extinguishers on Location: ______________________________________________

Staff was aware of location of fire and prepared to evacuate through appropriate Exits:
________________________________________________________________________
________________________________________________________________________

Staff from departments other than Nursing at appropriate posts:

________________________________________________________________________

________________________________________________________________________
Staff Co-operation:
________________________________________________________________________

2) Reason for Alarm (if not a planned drill): _____________________________________

3) Communication to Switchboard: ____________________________________________

4) Additional Comments: ____________________________________________________

5) Problems Identified/Recommendations: ______________________________________

Signed: _______________________ Position: _________________________

 Ind. 20
Staff members are trained for their role in
case of such emergencies
 AL SHIFA SURGICAL HOSPITAL

Office Order
It is hereby directed that all the staff of Al Shifa Surgical Hospital will attend the training
on fire emergency plan and evacuation plan on dated 14-11-2023 at 3:00pm sharp in
CEO office. In case of non-compliance strict disciplinary action will be taken against the
concern by authority.

Chief Executive Officer

Al Shifa Surgical Hospital
 ATTENDANCE SHEET
Training on Fire Emergency and Exit Plan
Date. ------------------- Time---------------

Sr. Name Designation Signature

No
Chief Executive Officer