Facilities – Plant / Systems Failure

Subject: Facilities
Setting: Property

Plant/systems failure is the failure of critical systems/equipment. A critical system is any system whose ‘failure’ could threaten human life, the system’s environment or the organization which operates the system.

Examples include:

  • Failure or impairment of fire suppression systems;
  • Water leaks/flooding/contamination;
  • Sump pump failure;
  • Heating, ventilation and air conditioning (HVAC) systems impairment/failure;
  • Boiler/water heater failure;
  • Electrical infrastructure (including transformers and switchgear) issues;
  • Fuel tank leaks;
  • Emergency power systems (generator) failure;
  • Telecommunication systems issues;
  • Medical gas delivery concerns;
  • Aging infrastructure;
  • Elevator failure, etc.

This document contains information entered by HIROC subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Ranking/Ratings 

  • Likelihood – average score 2.64
  • Impact rating – average score 3.46

The Risk Register allows for risks to be assessed on a five-point likelihood and impact scale, with five being the highest.

Key Controls / Mitigation Strategies

  • General
    • Comprehensive hospital emergency code procedures in place (code response teams)
    • Emergency numbers posted to call during ‘non-business’ hours
    • Staff are well trained in what to do during an emergency situation (staff roles and responsibilities)
    • Staff orientation and training
    • Emergency Plan Manual
    • Disaster Recovery/Emergency Recovery Plan/Business Continuity Plan in place
    • Root cause analysis (RCA) and/or failure mode and effects analysis done on any critical events
    • Request for service ticketing system
    • Service agreements with host hospitals
    • Supply chain agreements
    • Adequate insurance policy in place 
  • Power Supply
    • Back-up generators/dual transformers/emergency power (red electrical outlets) for all critical equipment and systems e.g. uninterrupted power supply (UPS) for information systems
    • Multiple back-up units with separate feeds
    • Preventive maintenance program in place for all generators 
    •  Alternate/adequate fuel supply for generators maintained on site
    • Fuel supplier contracted to provide service should the fuel supply need to be replenished for the generator
    • Hierarchy of equipment utilized with generator supply
    • Contact numbers for the electrical utility provider to provide updates on the situation and ETA (estimated time of arrival) for repairs
    • Agreements have been made with vendor to provide a portable generator and electrician if the facility generator fails
    • Contractors on call 24/7 to service
    • Engineer on call responds to all power generating situations
    • Consider installation of transfer switch allowing the use of chillers during power outages
    • Hangar doors can be opened via small generator or manually (to continue service)
  • Medical Gas Source/Delivery
    • Crisis escalation procedures in place
    • Multiple system redundancies 
    • Emergency back-up medical gas manifolds in critical care areas
    • Back-up oxygen system for source failure external to building 
    • Standby oxygen and medical air cylinders for localized system failures
    • Oxygen, medical air and vacuum failure policy and procedure
    • Portable suction units available in the event of vacuum failure
    • Preventive maintenance plan for all suction pumps and medical gas outlets
    • Annual inspection is done on oxygen and suction by manufacturer to change filters and oil to ensure compliance to obtain certification
    • Bracket system to minimize outlet leaks
    • Respiratory therapist on call for emergencies
    • Partnership between respiratory therapy and plan operations
    • Alarm systems in place across the hospital
    • Space banks of oxygen are onsite to ensure constant supply
    • Education provided on an annual basis
  • Aging Infrastructure
    • Regular preventive maintenance and testing of systems to observe performance and ensure functionality
    • Comprehensive corrective and preventive maintenance program to deal with failing infrastructure and equipment
    • Capital planning for replacement of aging facilities, equipment
    • Dedicated funds allocated for upgrades of aging infrastructure
    • Continuous efforts to apply for grants and funded infrastructure projects
    • Pipe replacement (galvanized iron pipe to steel pipe)
    • Transitioning from aging telephone ‘PBX’ (private branch exchange) to digital lines
    • Repair any localized leaking areas (roof)
    • Asset Management policies and procedures 
    • Maintenance of asset control system including an asset count and critical asset rating
    • Maintenance vulnerability assessment completed
    • Policies and procedures for the utilization of the Computerized Maintenance Management System (CMMS) and the maintenance supporting software
    • Registering assets on the CMMS with appropriate preventive maintenance tasks and frequencies for all major equipment 
  • Water/Steam
    • Standard operating procedure in place for water/steam loss
    • Building automation system is integrated with building operator pager
    • Domestic water isolation valves used to provide flow logic (selecting one flow path versus another) for maintenance or safety
    • Technical Standards and Safety Authority (TSSA) inspection annually
    • Replacement of boiler system from wing-wide temperature control to room-specific temperature control
    • Preventive maintenance/inspection procedures in place for boilers and tanks
    • Sites staffed 24/7 with Power Engineers for first response
    • Scheduled preventive maintenance checks for grounds and checks/preparation performed on advisory of pending weather events
    • Chemical treatment of water towers
    • Instantaneous hot water heaters
    • Semiannual disinfection and cleaning of ice machines
    • Personal Protection Equipment (PPE) required by staff accessing cooling towers
    • Contractors on call to service building
    • The city Public Works department can be accessed for an update on circumstances if it is due to city infrastructure
    • Supply of bottled water at each site for cooking and drinking
    • Nursing staff have access to moist wipes to care for Residents and Patients
    • Linen and dry food supply are sufficient to provide for Residents and Patients if water is not available
    • Ensure snow is removed from the flat roof
    • Annual orientation for mechanics on location of valves and how to shut off
    • Mitigation plan developed in collaboration with property insurer 
  • Fire Suppression
    • Fire pump maintenance
    • Annual fire education
    • Facility signage
    • One-on-one training for charge nurses
    • Meet fire regulations 
    • Fire panel and floor plan match
    • Fire alarm system is under maintenance contract and is serviced regularly
    • Fire monitoring systems in place at all sites
    • Fire sprinkler systems in place at all sites
  • Heating, Ventilation and Air Conditioning (HVAC) Systems
    • Contractors on call 24/7 to repair HVAC system
    • Preventative maintenance checks completed regularly
    • Portable fans for the hallways to keep the air circulating
    • Facility has primary and secondary heating system to maintain heat in building
    • Extra blankets and linen on hand should the temperature fall below 22 degrees
    • Alarm systems in place to alert when systems stop running
  • Elevator Systems
    • Elevator contractor is available 24/7 to answer calls
    • Emergency call feature in each elevator that passengers can access for help
    • Staff members are instructed to check for any passengers if an elevator is not working
    • Policy for elevator failure and entrapment 
  • Negative Air Flow Rooms
    • Weekly maintenance of negative air flow rooms completed by contractors
    • Pre-use check sheets available for staff, and instructions on entry provided to staff
       

Monitoring / Indicators

  • General
    • Strict monitoring of the environment and facility conditions
    • Audit records kept per legislation requirements
    • Maintenance activities
    • Incident reports and tracking of equipment failures
    • Capital Planning requests
    • Downtime and event debriefs
    • Codes tracking and debriefing
    • Staff feedback at team meetings (standing agenda item)
    • Monthly safety checks and inspections
    • Annual review of insurance policy
  • Water/Steam
    • Organizational reporting system to report stained tiles or water leaks
    • Plant engineering and plumber routinely monitors for evidence of new or recurring water leaks
    • Brine consumption
    • Visual inspection of brine tanks
    • Monitoring use of wipes with Patients who tend to flush things down the toilets
    • Monitoring pipes and toilet function regularly to watch for potential breaks
    • Scheduled inspections of mechanical spaces after regular hours
    • Floodplain assessments 
    • Monitoring snow levels on the roof
    • Monthly testing of cooling towers during operation
    • Monthly legionella testing of water systems by vendor
    • Weekly dipslide bacterial testing of water systems
    • Daily chemical testing of water systems
    • Monitor and read water meters every 3 hours and capture irregularities
  • Medical Gas Source/Delivery
    • Yearly inspection of all medical gas outlets (including leaks) of oxygen, air and vacuum by external partner
    • Monitoring of alarm panels and upgrades
    • Daily and weekly checks in place
    •  Oxygen system monitored throughout hospital at various control valves
    • Daily readings are taken at the supply tanks
  • Fire Suppression
    • Fire pump system monitored for pressure 
    • Annual inspections of the fire panel
    • Quarterly inspections of the suppression system
    • Annual inspection/certification of sprinkler systems
    • Monthly fire drills
    • Yearly fire alarm testing 
    • Monthly fire extinguisher inspections
    • Code red response
    • Weekly fire pump testing
  • Power Supply
    • Generators exercised/tested weekly
  • Aging Infrastructure
    • Monitor roof condition
    • Regular roof walks to keep drains clear and functioning and damage free
  • Elevator Systems
    • Monthly maintenance inspections
    • TSSA does regular inspections and licenses renewed on an annual basis
  • Negative Air Flow Rooms
    • Daily checks of negative air flow rooms completed by engineering resources