Facilities – Plant / Systems Failure

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

Risk Watch (October '25)

Documentation: Answers to Frequently Asked Questions

Patient/Client Falls