Health Sector EHSMS Requirements, v.2.1

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Health Sector EHSMS Requirements, v.2.1
Health Authority – Abu Dhabi
Document Title:
Health Sector EHSMS Requirements Version 2.1
Document Ref.
Number:
HAAD/EHSMS/ST/0000/HS_EHSMS/V2.1
Version:
2.1
Approval Date:
08 June 2015
Effective
Date:
June 2015
Last reviewed Date:
May 2015
Next Review:
June 2016
Revision History:
Version 1 issued July 2011
Document Owner:
Health Regulation/EHSMS
Applies to:
Licensed and Nominated Healthcare Providers in the Emirate of Abu Dhabi
Classification:
Pulblic
Health Sector EHSMS Requirements
Version 2.1
March 2015
Health Sector EHSMS Requirements - Version 2.1- March 2015
Page 1 of 34
Table of Contents
1.
Scope ....................................................................................................................................3
2.
Health Sector OHS Policy .....................................................................................................6
3.
Health Sector OHS Targets and Objectives...........................................................................7
4.
Additional Sector Reporting Requirements ..........................................................................10
5.
Health Sector Emergency Management Program................................................................15
6.
Health Sector Audit and Inspection Program .......................................................................18
7.
Health Sector Non-Conformance and Enforcement Process ...............................................21
Appendix A: Outline of Entity Emergency Management Plans ........................................................23
Appendix B: Health Sector Legal and Regulatory Requirements.....................................................24
Appendix C: Low Risk Entity Checklist ............................................................................................29
Appendix D: Summary of Implementation Requirements under the New Risk Classification of Entities
………………………………………………………………………………………………………………....34
Health Sector EHSMS Requirements - Version 2.1- March 2015
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1. Scope
1.1
Health Sector EHSMS Requirements
The Health Sector EHSMS Requirements Document outlines the core components and
requirements developed in full compliance with the AD EHSMS RF requirements as per AD
EHS RI- Mechanisms 2.0-AD EHSMS Sector Requirements and are as follows:

Health Sector OHS Policy;

Health Sector OHS Targets and Objectives;

Additional Sector Reporting Requirements;

Health Sector Risk-Based Emergency Management Program;

Health Sector Audit and Inspection Program; and

Health Sector Non-Conformance and Enforcement Process.
The Health Sector EHSMS requirements are a risk-based system designed to manage
identified Occupational Health, and Safety Hazards which have the potential to affect,
influence, impact and threaten Health Sector Entities operations, and define the required
control measures (As Low As Reasonably Practicable- ALARP), programs, procedures and
actions through which they can prevent/ eliminate, mitigate, prepare, respond to and recover
during normal and emergency operations.
The classification of Entities is carried out by the Health Authority Abu Dhabi (HAAD). The
criteria for classification is based on risks that includes nature and complexity of operations,
number of employees, use and storage of hazardous materials, proximity to residential or
sensitive communities, and number of beds. All Health Sector Licenced Entities shall be
classified as High, Medium or Low Risk Entities accordingly. High Risk Entities shall be
required to develop, implement and maintain a full EHS Management System. Medium Risk
Entities assessed against specific criteria and based on the results it may require to develop,
implement and maintain a full EHS Management System or follow the requirements of
Mechanism 05 of AD EHSMS RF. While low Risk Entities classified by the SRA are not require
to develop EHS Management System, however the Low Risk Entity will be inspected by
Health Sector SRA on a regular basis to ensure their compliance with a Low Risk Entity
Checklist Requirements (Appendix C).
1.2
Health Sector Scope
The scope of Health Sector EHSMS Requirements applies to all Health Sector related
activities, products and services provided by or at licensed and Nominated Healthcare
providers including the following :

General administrative and office work, IT services

Providing medical diagnostic, consultation, treatment and rehabilitation services for
inpatient and outpatient mainly (but not limited to) the following clinical areas:
•
Emergency medicine, first aid
•
Intensive care/Paediatric intensive care (ICU/PICU)
Health Sector EHSMS Requirements - Version 2.1- March 2015
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•
Internal medicine (including e.g. haematology, oncology, infectious diseases, travel
medicine, clinical immunology, rheumatology, gastroenterology, endocrinology,
cardiology, pulmonology, nephrology, haemodialysis, sleep disorders, nutrition)
•
Surgery (including e.g. trauma, orthopaedic, neuro & brain, craniofacial, dental,
cardiac, thoracic, vascular, abdominal, transplantation, plastic, and cosmetic surgery)
•
Anaesthesiology, blood transfusion, pain therapy
•
Physiotherapy, rehabilitation, balneotherapy
•
Neurology, Behavioural therapy, Psychiatry
•
Obstetrics and Gynaecology (O&G)
•
Urology
•
Neonatology, Paediatrics
•
ENT (Ear, Nose, Throat) incl. hyperbaric oxygen (HBO) therapy and allergology
•
Ophthalmology and optometric services
•
Dermatology
•
Dental services
•
Medical imaging (e.g. ultrasound, radiology, CT, NMR)
•
Clinical laboratory (e.g. clinical chemistry, haematology, microbiology, immunology,
serology, molecular biology, toxicology, infection control)
•
Pharmacy
•
Blood bank
•
Radiation therapy, Nuclear medicine
•
Histopathology, biopsy, Forensic medicine, morgue

Providing preventative and public health services including but not limited to: infection
control, smoking cessation counselling, breast cancer awareness and early detection,
vaccination, medical screening, disease and injury surveillance, mortuary services,
occupational health, fitness to work, dental and school health services.

Reprocessing of medical equipment (e.g. cleaning, disinfection, and sterilization)

Food handling and catering

Cleaning, disinfection, and sterilization of medical products and equipment

Laundry services, cleaning, housekeeping and waste management

Maintenance, technical and facility management services, including contracted services

Awareness, training and education activities, CME/CPD

Medical and Public Health research.
Any other activities, products or services not listed above that take place at a licensed
Healthcare Facilities that may pose a risk to healthcare workers, contractors, subcontractors,
patients and visitors are included in the scope of EHSMS. Any other Facilities not licensed by
HAAD are excluded and not covered by the Health Sector EHSMS.
Health Sector EHSMS Requirements - Version 2.1- March 2015
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Under the scope of the Health Sector EHSMS the implementation and reporting of
performance will be provided by the Health Authority- Abu Dhabi (HAAD) who is the Sector
Regulatory Authority (SRA) for the Health Sector based to Abu Dhabi Executive Council
Decree No. (42) of 2009. HAAD will implement and report on the EHS Performance for all
Health Sector Nominated Entities to the Abu Dhabi EHS Center (OSHAD).
HAAD will also gather additional sector specific KPI’s as mentioned in Section (4) of this
document, “Additional Sector Reporting Requirements” in line with the AD EHSMS-Element
07-Monitoring, Investigation, and Reporting.
Any future additional requirements related to the scope of the Health Sector EHSMS will be
updated in this Section of the document upon the completion of a regular review and process
updating in cooperation with AD EHS Center (OSHAD) as required.
Health Sector EHSMS Requirements - Version 2.1- March 2015
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Health Sector EHSMS Requirements - Version 2.1- March 2015
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3. Health Sector OHS Targets and Objectives
KPI
Description
What should be reported?
Target or
Trend
Abu Dhabi OHS Mandated KPI’s
Occupational Health and Safety Incident and Consequence Summary for the employee of the entity and
other persons.
2-01
Total OHS Incidents
Reduce (5%)
by end of
2015
 Sum of KPI 2-02, 3-01 & 4-01
Occupational Health and Safety Performance for Entity - Compulsory Reporting to Health Sector Authority
2-02
Total OHS Incidents /
Consequences for employees







2-03
Total Reportable Case
Frequency (TRCF)
2-04
Lost Time Injury Severity Rate
(LTISR)
2-05
Lost Time Injury Frequency
Rate (LTIFR)
2-06
Number of Near Miss & First
Aid Cases for employees






Lost Time Injuries
Restricted Workday Case
Medical Treatment Case
Total Injuries & Illness for calculating KPI 203 (TRCF)
Total Lost Workdays for calculating KPI 2-04
(LTISR)
Serious Dangerous Occurrence
Equipment/Property Damage
Number of Total Injuries & illness Reported
in the Reporting Period
Number of working Hours in Reporting
Period
Number of Workdays lost due to Injuries &
Illness in the Reporting Period
Number of working Hours in Reporting
Period
Number of Lost Time Injuries in the
Reporting Period
Number of Working Hours in Reporting
Period
 Near Miss (NM)
 First Aid Cases (FA)
Health Sector EHSMS Requirements - Version 2.1- March 2015
Reduce (5%)
by end of
2015
Reduce (5%)
by end of
2015
Reduce (5%)
by end of
2015
Reduce (5%)
by end of
2015
Increasing
Reporting of
NM &
Decreasing
Trend for FA
by End of
2015
Page 7 of 34
3-01
Total Incidents/Consequence
for Contractors





Lost Time Injuries
Restricted Workday Case
Medical Treatment Case
Serious Dangerous Occurrence
Equipment/Property Damage
Reduce (5%)
by end of
2015
Number of Near Miss & First
Aid Cases for Contractors
 Near Miss (NM)
 First Aid Cases (FA)
Increasing
Reporting of
NM &
Decreasing
Trend for FA
by End of
2015
3-03
Number of Monitoring
Activities Performed on
Contractors/Supply chain by
Entity
 Total No. of Contractors
 Review/Approval of Contractors EHS
Procedures
 Specific Requirement/Part System Audit
Performed on Contractors
 Full EHSMS Audit Performed on Contractor
 Inspection Performed on Contractors
 Contractor Incidents Investigation by Entity
 Corrective Notices Issued to Contractors
 Breach Notices Issued to Contractors
Increasing
Trend/End of
2015
4-01
Number of Fatalities & Injuries  Fatalities
for other Persons
 Other Injuries
3-02
Decreasing
Trend/End of
2015
Number of Near Miss & First
Aid Cases for other Persons
 Near Miss (NM)
 First Aid (FA)
Increasing
Reporting of
NM &
Decreasing
Trend for FA
by End of
2015
5-01
EHS Department Resources
 Number of Employees in EHS Department
 Number of UAE Nationals in EHS
Department
 % of UAE nationals in EHS Department
 Number of Employees attended the AD
EHSMS Practitioner Course
 Number of Employees Registered at
Qudorat.
Increasing
Trend/End of
2015
5-02
Average no. of training hours
per employee
 Total no. of EHS training hours undertaken
by employees
Increase (5%)
by end of
2015
5-03
Third Party EHSMS
Compliance Audit
 3rd Party EHSMS Compliance Audit
conducted & Audit Report submitted to SRA
 EHSMS Compliance Audit is scheduled for
Increasing
Trend/End of
4-02
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2015
(insert date)

Number of Corrective Notices 



Number of Breach Notice

5-04
5-05
Number of warning notice received
Number of Improvement notice received
Number of Prohibition notice received
Number of Fines received
Number of enforceable undertakings
Total value of all fines. Penalties/
enforceable undertakings enforced (AED)
Decreasing
Trend/End of
2015
Decreasing
Trend/End of
2015
In order to measure progress against the above mentioned EHS targets and objectives,
related Health Sector EHSMS KPIs have been identified and specified in line with the
minimum Abu Dhabi EHSMS Regulatory Framework requirements.
These KPIs are allowing HAAD (on an entity level) and the AD EHS Center (OSHAD) (on a
sector level) to monitor the performance of Nominated Entities and the Health Sector mainly
with regards to:

EHSMS administration

Compliance of Nominated Entities with EHSMS requirements

Enforcement of EHSMS requirements by HAAD

OHS capacity and resources within HAAD and Entities

OHS Awareness and training activities

OHS incidents and investigations
All these KPIs must be monitored and reported by Nominated Entities to HAAD Health Sector
EHSMS Section who will report as required to AD EHS Center (OSHAD).
Targets for the KPIs reported will be set based on established baselines and in consideration
with international best practice. Baseline performance figures for most of the parameters are
currently unavailable and these will be used in future to set realistic performance KPIs for the
Health Sector and drive continual improvement in all areas of occupational health and safety
In addition some targets will be set once additional information is available on resources and
staffing availability within the HAAD EHSMS Section, training needs assessments are
conducted and additional data becomes available through feedback from the entities and from
outcomes of third party independent audits, reporting results and risk assessments. KPI
targets will be set and approval sought from HAAD senior management to enable the
continual improvement cycle to commence to drive change within the health sector towards
best international practice.
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4. Additional Sector Reporting Requirements
KPI
Description
What should be reported?
Target or
Trend
Health Sector Specific EHSMS KPI’s
Procedure-associated Healthcare-associated infections
HAI-01
SSI - Surgical Site Infections
For at least one commonly performed or
important surgical procedure in the reporting
period:
 Number of surgical procedures performed
 Number of surgical site infections
 Incidence rate of surgical site infections per
100 surgical procedures performed
Decreasing
Trend/End
of 2016
Device-associated Healthcare-associated infections
HAI-02
HAI-03
Ventilator-associated Pneumonia
(VAP)
Central-line-associated blood
stream infection (CLABSI)
HAI-04
Catheter-associated Urinary Tract
Infection (CAUTI)
HAI-05
Other healthcare-associated
infections and outbreaks (Other
HAI)
For ICU patients only, in the reporting period:
 Number of ventilator-days
 Number of cases with suspected or
confirmed VAP
 Incidence rate of cases with suspected or
confirmed VAP per 1,000 ventilator days
For patients with central line catheter only, in
the reporting period:
 Number of central line catheter days
 Number of cases with suspected or
confirmed central line-associated BSI
 Incidence rate of cases with suspected or
confirmed BSI per 1,000 central line days
For patients with urinary tract catheter only, in
the reporting period:
 Number of urinary tract catheter days
 Number of cases with suspected or
confirmed urinary tract catheter-associated
UTI in the reporting period
 Incidence rate of UTI cases per 1,000
catheter days
 Number of cases and outbreaks due to
o Healthcare-associated blood borne
infections (HIV/AIDS, Hepatitis B,
Hepatitis C)
Health Sector EHSMS Requirements - Version 2.1- March 2015
Decreasing
Trend/End
of 2016
Decreasing
Trend/End
of 2016
Decreasing
Trend/End
of 2016
Decreasing
Trend/End
of 2016
Page 10 of 34
o Healthcare-associated water borne
infections (L. pneumophila, P. aeruginosa)
o Healthcare-associated air borne
infections (Aspergillosis)
Patients colonized or infected with relevant MDRO (Multi Drug Resistant Organisms)
MDRO01
Methicillin-resistant
Staphylococcus aureus (MRSA)
 Number of patients colonized or infected
with MRSA in the reporting period
 Number of patients colonized or infected
with Clostridium difficile in the reporting
period
MDRO02
Clostridium difficile (CDIFF)
MDRO03
Vancomycin-resistant
Enterococci (VRE)
MDRO04
Extended spectrum betalactamase producing Escherichia
coli and Klebsiella spp. (ESBL)
MDRO05
Multi-drug/extended drug
resistant Mycobacterium
tuberculosis (MDR/XDR-TB)
 Number of patients colonized or infected
with VRE in the reporting period
 Number of patients colonized or infected
with ESBL in the reporting period
Number of patients colonized or infected with
 MDR-TB
 XDR-TB
in the reporting period
Decreasing
Trend/End
of 2016
Decreasing
Trend/End
of 2016
Decreasing
Trend/End
of 2016
Decreasing
Trend/End
of 2016
Decreasing
Trend/End
of 2016
Antibiotic Resistance Surveillance
See HAAD EHSMS Standard for HealthCare
Providers-Monitoring and Reporting of
Antimicrobial Resistance
AR-01
Staphylococcus aureus
AR-02
Streptococcus pneumonia
Decreasing
Trend/End
of 2016
AR-03
Enterococcus faecalis
Decreasing
Trend/End
of 2016
AR-04
Enterococcus faecium
Decreasing
Trend/End
of 2016
AR-05
Escherichia coli
Decreasing
Trend/End
of 2016
AR-06
Klebsiella spp.
Decreasing
Trend/End
of 2016
Health Sector EHSMS Requirements - Version 2.1- March 2015
Decreasing
Trend/End
of 2016
Page 11 of 34
AR-07
Salmonella spp.
Decreasing
Trend/End
of 2016
AR-08
Shigella spp.
Decreasing
Trend/End
of 2016
AR-09
Pseudomonas aeruginosa
Decreasing
Trend/End
of 2016
AR-10
Acinetobacter baumannii
Decreasing
Trend/End
of 2016
AR-11
Stenotrophomonas maltophilia
Decreasing
Trend/End
of 2016
AR-12
Neisseria gonorrhoeae
Decreasing
Trend/End
of 2016
AR-13
Mycobacterium tuberculosis
Decreasing
Trend/End
of 2016
AR-14
Candida albicans
Decreasing
Trend/End
of 2016
Workplace Environment Monitoring Results

EM-01
EM-02
Air Quality Monitoring
Water Quality Monitoring
Number of air quality monitoring tests
conducted in the reporting period
 Number of air quality monitoring test
results exceeding the acceptable limits of
the HAAD EHSMS Standard 11 – Air Quality
Standard
 Number of water quality monitoring tests
conducted in the reporting period
 Number of water quality monitoring test
results exceeding the acceptable limits of
the HAAD EHSMS Standard 12 – Water
Quality Standard
Health Sector EHSMS Requirements - Version 2.1- March 2015
Increasing
Trend/End
of 2016
Decreasing
Trend/End
of 2016
Increasing
Trend/End
of 2016
Decreasing
Trend/End
of 2016
Page 12 of 34
Environmental KPIs
Power Consumption
E-01
E-02
 Total kW h and kW h Per Employee for the
previous and current reporting period
(Total Kilowatts Hours (kW h) and
 Percentage Reduction or Increase (Indicate
kW h per Employee)
reduction as a negative figure e.g. –3.5 %)
Water Consumption
 Total m3 and m3 Per Employee for the
previous and current reporting period
Water use (in production

Percentage Reduction or Increase (Indicate
processes, office activities)
reduction as a negative figure e.g. –3.5 %)
(Total cubic meters (m3) and m3
per Employee)
Paper Consumption
E-03
Average number of paper pages
used per employee per month
Fuel Consumption
E-04
Average fuel consumption of
entity owned and /or operated
vehicles.
(Liters per 100 kilometers)
Non-Hazardous Waste Disposal
E-05
Amount of non-hazardous (solid
and liquid) waste collected by
Service Providers for disposal.
Non-Hazardous Waste Recycling
E-06
Amount of segregated nonhazardous (solid and liquid)
waste collected by Service
Providers for recycling / reuse /
further processing.
 Average No. of Pages used per Employee for
the previous and current reporting period
 Percentage Reduction or Increase (Indicate
reduction as a negative figure e.g. –3.5 %)
 Number of vehicles owned and/or operated
by entity for the previous and current
reporting period
 Average fuel consumption of vehicles
(Combined Cycle L/100 km) for the
previous and current reporting period
 Percentage Reduction or Increase (Indicate
reduction as a negative figure e.g. –3.5 %)
 Solid (kg) and Liquid (L) for the previous and
current reporting period
 Percentage Reduction or Increase for both
Solid (kg) and Liquid (L)(Indicate reduction
as a negative figure e.g. –3.5 %)
 Solid (kg) and Liquid (L) for the previous and
current reporting period
 Percentage Reduction or Increase for both
Solid (kg) and Liquid (L) (Indicate reduction
as a negative figure e.g. –3.5 %)
 Solid (kg) and Liquid (L) for the previous and
current reporting period
Amount of hazardous (solid and  Percentage Reduction or Increase for both
liquid) waste collected by Service
Solid (kg) and Liquid (L)(Indicate reduction
Providers for disposal.
as a negative figure e.g. –3.5 %)
Hazardous Waste Disposal
E-07
Health Sector EHSMS Requirements - Version 2.1- March 2015
Decreasing
Trend/End
of 2015
Reduce (5%)
by end of
2015
Reduce (5%)
by end of
2015
Decreasing
Trend/End
of 2015
Decreasing
Trend/End
of 2015
Increasing
Trend/End
of 2015
Decreasing
Trend/End
of 2015
Page 13 of 34
 Solid (kg) and Liquid (L) for the previous and
current reporting period
Amount of hazardous (solid and
liquid) waste collected by Service  Percentage Reduction or Increase for both
Solid (kg) and Liquid (L) (Indicate reduction
Providers for recycling / reuse /
further processing.
as a negative figure e.g. –3.5 %)
Hazardous Waste Recycling
E-08
Increasing
Trend/End
of 2015
Additional Health Sector-specific KPIs to monitor performance of Nominated Entities with
regards to Infection Control Management & Environmental KPIs have been identified. These
KPIs are allowing HAAD on an Entity-level to monitor:

Frequency and incidence rates of relevant Healthcare-associated infections

Frequency of colonization and infection of patients with Multi-Drug Resistant Organisms
(MDRO)

Levels and trends of antibiotic resistance of relevant pathogens isolated from patients

Frequency of environmental air and water sampling conducted and percentage of results
exceeding acceptable standards

Trends of environmental KPIs
All Health Sector-specific EHS targets and objectives have been communicated to Nominated
Entities by publishing on HAAD website, sending out emails, letters or circulars, conducting
information sessions and other means.
All Health Sector-specific EHS targets, objectives and programs will be reviewed periodically.
All these additional KPIs must be monitored and reported from Nominated Entities to Health
Sector EHSMS Section, but will not be reported to AD EHS Center (OSHAD).
Targets for the Infection Control KPIs reported will be set based on established baselines and
in consideration with international best practice. Baseline performance figures for most of the
parameters are currently unavailable and these will be used in future to set realistic
performance KPIs and drive continual improvement in all areas of infection control.
A Business Intelligence (BI) tool with statistical analysis and reporting functionality will be
developed as a back-end component to the e-system, which will allow for a full suite of
graphical and tabular reports and statistical analysis to be generated in real time for Entity
performance analysis.
Health Sector EHSMS Requirements - Version 2.1- March 2015
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5. Health Sector Emergency Management Program
5.1
Health Sector-Wide Potential Emergency Scenarios
In assessing the hazards and risks associated with healthcare activities, a number of typical
incident types need to be examined as scenarios for which emergency management and
response plans shall be developed. These scenarios are:

Spills or leaks of hazardous materials;

Fire and Explosive materials handling, such as compressed oxygen tanks;

Toxic exposures involving chemicals or radiation

Infection/intoxication with bio-hazardous materials, pathogens and toxins, including
outbreak scenarios, e.g. Influenza.
Each Nominated Healthcare Provider must in cooperation with HAAD Operation Center
develop, implement and maintain an appropriate EHS Emergency management Program(s)
(EMP’s)/Plan(s) as part of the Entity EHSMS, which addresses emergency planning and
response to EHS emergencies within the Facility.
Emergency Management Program (EMP’s)/plan(s) shall address, at a minimum (refer
Appendix A):

Overall accountability for the program;

Specific emergency management roles, responsibilities and resources,

Risk-based identification of potential emergency situations;

Appropriate risk-based and linked Emergency Response Plans, complete with
escalation tiers and procedures.

Provision of appropriate resources (human, facilities, equipment, training);

Arrangements for external stakeholder liaison, communications, requirements and
support actions;

Arrangements for communications with local authorities and emergency services;

Periodic emergency response tests and exercises; and

Monitoring and review of programs/plans and procedures.
Entities have to identify and assess their relevant specific Aspects and Hazards as well as
potential Emergencies, Crisis and Threats within their scope of operations. This process shall
be subject to continual review, assessment and modification during the course of the Health
Sector EHSMS implementation within the Sector Entities in cooperation, coordination,
communication and consultation with HAAD Operation Center as per HAAD Policy on
Managing Major Incidents, Disasters and Large Scale Public health Emergencies in the
Emirate of Abu Dhabi.
The above requirements are related to, and has effect together with the HAAD EHSMS
standard (HAAD/HSED/ST/0006/HS_EHSMS- Emergency Management).
Health Sector EHSMS Requirements - Version 2.1- March 2015
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5.2
Health Sector Emergency Management Organization, Roles & Responsibilities
5.2.1
HAAD Operations Center needs to be contacted immediately in case of any emergency within
the facilities or on the premises of an EHSMS Nominated Healthcare Facility that require
further guidance, support, directions or coordination from HAAD as the concerned Sector
Regulatory Authority (SRA) for the Health Sector EHSMS.
5.2.2
Emergencies that require immediate notification of HAAD Operations Center include, but are
not limited to the following:

Fire, requiring fire fighting measures by professional fire fighters and/or evacuation of
patients and staff;

Explosions, leading to medium/major damage, injury or death;

Release of hazardous materials or biological agents with acute or imminent danger of
exposure or infection of humans within or outside the healthcare facility;

Building collapses;

Outbreaks of communicable diseases;

Any emergency situation that leads to a number of injured patients that cannot be
effectively handled by the Healthcare Provider alone and requires support from other
suitable healthcare facilities nearby;

Any emergency situation that requires the emergency evacuation of patients and staff.
5.2.3
HAAD Operation Center is operated 24 hours, 7 days a week and can be contacted by Tel.
02 4193666 or email [email protected]
5.2.4
HAAD Operation Centre’s role in case of the above mentioned and other emergencies is as
follows:

Provide guidance, support, assistance and directions as requested, reasonable,
applicable or necessary to the EHSMS Nominated Healthcare Provider in order to
minimize the negative impact of the event on health and wellbeing of staff, patients,
visitors and contractors of the Facility;

Inform the Chairman and all members of the HAAD Emergency and Disasters
Management Committee about the event, call for an immediate meeting of the Committee
if necessary, and request the feedback and support of the Committee as necessary and
applicable;

Coordinate information exchange and necessary activities with other governmental and
non-governmental agencies and entities (e.g. Abu Dhabi Health Services Company
(SEHA), Abu Dhabi Police Quick Intervention and Technical Rescue Dept., etc.);
Health Sector EHSMS Requirements - Version 2.1- March 2015
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5.2.5

Support and coordinate the mobilization, allocation and supply of necessary health,
human, technical and other resources to the site of concern to successfully manage the
emergency situation;

Coordinate healthcare facility(s) and medical response to the emergency;

Direct the provision of public health services to prevent, prepare for, respond to, and
recover from emergencies, and

Direct and coordinate public health communications during emergency, including during
response and subsequent recovery from injuries.
Duties arising during Emergencies

5.3
In the event of an emergency, healthcare providers, blood banks, mortuaries, vaccination
centers and payers must
a)
comply with all HAAD directives to prepare for, prevent, mitigate the impact of, and
care for people affected by the Emergency, including, but not limited to treatment
and prophylactic measures;
b)
provide any information, assistance and advice requested by HAAD; and
c)
Comply with any other actions as directed by HAAD.
Health Sector Emergency Communications with Stakeholders, local Authorities
and Emergency Services
5.3.1 Sector Communication
In the event of a major incident or emergency situation (Serious personal injury, fatality, fire,
etc.) immediately contact your appointed EHS liaison Representative within the Entity who
shall assess the situation and immediately report to:

First: Local Emergency Services by dialling (999)

Second: HAAD Operation Center by dialling (02 4193 666) or by email: [email protected] ,
as per HAAD Standards on Major Incident and Disaster Preparedness in Healthcare1.
When transmitting a message by telephone, or by any other means of communication always
ensure that you clearly identify yourself by giving:
1. Your Name;
1
HAAD Standards on Major Incident and Disaster Preparedness in Healthcare, Ref. Nr. HAAD/HHPS/SD/1.0
Health Sector EHSMS Requirements - Version 2.1- March 2015
Page 17 of 34
2. Your Exact Location;
3. Nature of Incident or Emergency; and
4. Service/ Help Required and Repeat The Message Again.
5.4

Third: Health Sector EHSMS Section by completing and sending Form G “Incident Notification
Form” via email: [email protected] as per the Mechanism 6.0 “EHSMS Performance & Incident
Reporting”. V2.1 Dec. 2013 of AD EHSMS RF.

Health Sector Entities shall communicate and coordinate major incidents and emergencies to
Health Sector EHSMS Section as per the requirements of AD EHSMS RF:
o
Fatality shall be reported within 24 hours
o
Serious Injuries and Illness shall be reported within 3 days.
Health Sector Emergency Drills/ Exercises & Periodical Monitoring and Review
of Emergency Plans & Procedures
Health Sector Entities and Health SRA shall respond to each incident, emergency or crisis
situation as appropriate on an efficient and effective manner. This will be achieved through the
support and consistent provision of information, instruction, training and regular practice drills
and exercises on all identified and potential incidents, emergency and crisis scenarios and
situations. Periodical monitoring, Testing, Inspection and Auditing of Abu Dhabi Health Sector
and Entities Emergency Management Programs shall be conducted at least annually to
establish the effectiveness of training and practice drills.
The Health Sector Emergency program shall comply with the AD EHSMS RF - Element 06 –
Emergency Management Section 3.
6. Health Sector Audit and Inspection Program
The Health Sector Audit and inspection program shall comply with the AD EHSMS RF Element 08 – Audit and Inspection Section 3.
6.1
Sector EHS Audit Categories:
Internal EHS Audits:
Internal EHS audits are audits conducted by the audit team of the Nominated Entity (HCP) to
identify compliance and non-compliance with the Entity EHSMS system and legal
requirements and to ensure that all EHS relevant procedures are conducted in line with the
Entity EHSMS requirements.
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External EHS Audits:
External EHS audits are audits that are required by the AD EHSMS RF in form of annual
external third party independent audits of the Entity EHSMS. Auditors shall be competent and
qualified and must be registered with the AD EHS Center (OSHAD). The annual third party
audit shall be conducted within 30 Days of completing 1 year of approval date (Note: 3rd
Party Audit Report shall be submitted within 30 days of receiving the Audit Report). The
annual third party audit reports shall be submitted to HS EHSMS Section.
Health Sector Regulatory Authority (SRA) audits:
SRA audits are audits conducted by HAAD auditors. Sector Regulatory Authority audits may
be conducted at any time with notice by HAAD Health Audit Dept. and/or HAAD Health Sector
EHSMS Section staff. All EHS audit records must be kept at least for 5 years and presented to
HAAD upon request.
6.1.1 Sector EHS Annual Audit Frequencies
Entity Risk / Audit Type
Internal
External
HS SRA
1
Minimum 1
1
Minimum 1
Not Required
0
0
Not Required
0
0
1 x to cover AD EHSMS RF
and HS EHSMS Requirements
+ Standards
High
&
Min. of 3 x for high risk
activities and departments
Medium
1 x to cover AD EHSMS RF
and HS EHSMS Requirements
+ Standards
(Full EHSMS System)
&
Min. 3 x for high risk activities
and departments
Medium
(Mechanism 5)
Low
EHS Audit Frequencies per Entity Risk per year
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6.2
Sector EHS Inspections Categories:
EHS Planned Inspections: Are inspections to be conducted on regular basis and intervals;
planned inspections are inspections scheduled in advance to take place at a certain time and
date. These inspections are generally done in accordance with the hazards associated with
the facilities operations and its potential for serious EHS incidents and threats.
EHS Random Inspections: Health SRA shall conduct random/ surprise EHS inspections of
Entity operations to insure the effectiveness and efficiency of EHSMS. Entities shall not be
informed of the Random Inspections prior to inspections.
6.2.1 Sector EHS Annual Inspection Frequencies
HS SRA
HS SRA
(Random)
(Planned)
Risk Based
1
Minimum 1
Risk Based
1
1
Risk Based
As required
1
As required
1
Entity Risk /
Inspection Type
Internal
High
Medium
(Full EHSMS System)
Medium
(Mechanism 5)
Low
Risk Based
(minimum of 2 times)
EHS Inspection Frequencies per Entity Risk per year
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Page 20 of 34
7. Health Sector Non-Conformance and Enforcement Process
7.1
Health Sector EHSMS Non- Conformance Process
The output of Audits or Inspections shall be either Conformance and/ or Non-Conformance. If
Entities are in full compliance and conformance with the Health Sector EHSMS Requirements
and Abu Dhabi EHSMS Requirements, the Health SRA. shall acknowledge those Entities
through appraisal certificate.
If any deviation is found as output of Audits or Inspections that may lead to Non-Conformities
and a state of non-compliance the root cause of the non-conformance shall be investigated
and corrective action shall be taken within the time specified by Health SRA.
HAAD may impose sanctions in relation to any breach of the EHSMS Policy and the related
EHSMS Standards, including warnings, improvement notices, prohibition notices, and
suspension or revocation of a license of a Nominated Health Care Provider in accordance with
the Draft HAAD Health Sector Violations and Penalties procedure.
Decisions on sanction and penalties will be determined by considering the circumstances of
the case and be consistent with the terms and procedures of the HAAD Licensing Committee
and in accordance with the measures under the law.
Warnings, and improvement or prohibition notices might be recommended by the HAAD
Health Sector EHSMS Section, HAAD EHSMS and Special Audit Department, HAAD Health
Audit Department or other concerned HAAD Departments and Sections based on evidence of
continuous non-compliance and are issued by either the Director General or one of the HAAD
Division Directors.
For temporary suspension or revocation of Healthcare Facility licenses a formal review and
decision by the HAAD Healthcare Facility Licensing Committee is required.
(Note: this is to be included as per mandate of the SRA and until Enforcement Process is
standardized by the AD EHS Center (OSHAD) at Emirate level).
The Health Sector non-conformance and enforcement process shall comply with the AD
EHSMS RF - Element 01 – Roles, Responsibilities and Self-Regulation Section 5.
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Page 21 of 34
HAAD Health Sector EHSMS List of Violations and Penalties
No.
1
2
3
4
5
6
7
8
9
10
11
Violation/complaint
Penalty - First
Infraction
Penalty - Second
Infraction
Penalty - Third
Infraction
Penalty Fourth
Infraction
Failure to register with HAAD
for development of EHSMS by
date notified
Failure to Amend Entity
Information and/or Authorized
EHSMS contact person details
and keep up to date
Failure to commence
development of entity EHSMS
by dates notified
Failure to submit EHSMS
documentation for Review and
Approval by dates notified
Failure to commence
implementation of entity
EHSMS by dates notified
Failure to notify HAAD of
implementation of EHSMS and
submit declaration of
Implementation
Failure to submit incident
report and/or in time frames
specified and/or with details
required
Failure to submit incident
investigation report and/or in
time frames specified and/or
with details required
Failure to submit quarterly
report and/or in time frames
specified and/or with details
required
Failure to submit annual third
party report and/or in time
frames specified and/or with
details required
Warning to the
Facility
Owner/Manager
Warning to the
Facility
Owner/Manager
Warning to the
Facility
Owner/Manager
Temporary
suspension of
Facility
license
Failure to comply with HAAD
EHSMS Requirements and
standards per violation.
Warning, and
improvement or
prohibition
notice to the
facility
Owner/Manager
Warning, and
improvement or
prohibition
notice to the
facility Owner/
Manager
Warning, and
improvement or
prohibition
notice to the
facility Owner/
Manager
Temporary
suspension or
withdrawal of
facility license
(Note: This is to be include as per mandate of the SRA and until Enforcement Process is
standardized by the AD EHS Center (OSHAD) at Emirate level).
Health Sector EHSMS Requirements - Version 2.1- March 2015
Page 22 of 34
Appendix A: Outline of Entity Emergency Management Plans
1.0
2.0
3.0
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
4.0
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
5.0
5.1
5.2
6.0
7.0
8.0
Policy Statement
Purpose and Scope
Pre-Emergency Planning
Hazard Identification
Risk Analysis
EHS Management System and Standards Requirements
Emergency Organization Responsibilities
Resources and Training
Internal Alerting
External Alerting
Communications
Public Affairs
Emergency Response
Response Action Decision Making
Plan Activation and Response/Communications Mobilization
Response Action/Containment/Isolation/Quarantine/Clean-up
Emergency Operations Centre and Liaison
Evacuation and Accountability
Management of Contaminants and Debris
Site Restoration/Remediation
Incident Investigation, Debriefing and Post-Incident Evaluation
Reporting (Internal and to HAAD)
Training and Practice Drills
Training records
Practice Drills summary reports
Plan Evaluation Reports
Plan Updates
Appendices and Operational Guidelines
Health Sector EHSMS Requirements - Version 2.1- March 2015
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Appendix B: Health Sector Legal and Regulatory Requirements
Standard reference number
HAAD Healthcare
Providers EHSMS
Standard Name
Decree No. (42) of 2009 Concerning AD EHSMS
AD EHSMS Regulatory Framework (Version 02/2012)
Legal Reference
Responsible
Person/ Entity
Specific action

The Abu Dhabi EHSMS Regulatory Framework,
Elements 06 – Emergency Management, Version 2.0,
Feb 2012.
The Abu Dhabi EHSMS Regulatory Framework, Code
of Practice 6.0 – Emergency Management, Version
2.0, Feb 2012.
HAAD Standards for Reporting of Public Health
Statistics (HAAD/PHST/SD/VIPCD/1.2), August 2013;
HAAD EHSMS Standard 0017 – Infection Prevention
and Control Management;
HAAD Standards for Major Incident and Disaster
Preparedness in Healthcare (HAAD/HHPS/SD/1.0);
HAAD Guidelines for Health Facility Design, Approvals,
Construction and Consultant Prequalification. Part C –
Access, Mobility, OHS and Security. Version 2,
07/09/2010.
The Healthcare
Provider’s
authorized
EHSMS person
including the
entities EHSMS
Unit and all
identified
personnel, fire
marshals and first
aiders.
Analysing and
developing an
emergency plan for
the Healthcare
Provider’s facilities,
accompanying
letters of
appointment and
incident reporting
structure.
Federal Environmental Law No. (24) or 1999 for the
Protection and Development of the Environment;
Technical Guidance Document for Submission of
Environmental Impact Assessment Report – 2009.
The Healthcare
Provider’s
authorized
EHSMS person
including the
entities EHSMS
Unit.
Conduct a
systematic
Environmental,
Health and Safety
Impact Assessment
(EHSIA) for projects
and/or Healthcare
Provider facilities
before any
significant
construction,
modification,


HAAD/HSED/ST/0006/HS_EHSMS
Emergency
Management





HAAD/HSED/ST/0007/HS_EHSMS
Environmental,
Health and Safety
Impact
Assessments
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Page 24 of 34



HAAD/HSED/ST/0011/HS_EHSMS
Ambient Air
Emissions, Indoor
Air and
Occupational Air
Quality
Management





HAAD/HSED/ST/0012/HS_EHSMS
Water Quality


Health Sector EHSMS Requirements - Version 2.1- March 2015
The Abu Dhabi EHSMS Regulatory Framework. Code
of Practice. AD EHSMS CoP 52- Local Exhaust
Ventilation. Version2.0, Feb 2012.
The Abu Dhabi EHSMS Regulatory Framework Technical Guideline Occupational Air Quality, Version
2.0, Feb 2012.
ASHRAE Standard 170-2008: Ventilation of Health
Care Facilities.
http://www.ashrae.org/.
ASHRAE Standard 62.1-2007: Ventilation for
Acceptable Indoor Air Quality.
http://www.ashrae.org/.
HAAD Facilities EHSMS Standard 0017 – Infection
Prevention and Control Management.
Draft Cabinet Resolution 2009 Regarding Hazardous
Medical Waste Management.
CDC Guidelines for Environmental Infection Control
in Health-Care Facilities. Recommendations of CDC
and the Healthcare Infection Control Practices
Advisory Committee (HICPAC). MMWR June 6, 2003 /
52(RR10);1-42.
The Healthcare
Provider’s
authorized
EHSMS person
including the
entities EHSMS
Unit and related
entity Facility
Management.
The Water Quality Regulations 2009. Issued by: The
Regulation and Supervision Bureau for the Water,
Wastewater and Electricity Sector in the Emirate of
Abu Dhabi. July 2009. Available online at
http://www.rsb.gov.ae.
The Water Supply Regulations 2009. Issued by: The
Regulation and Supervision Bureau for the Water,
Wastewater and Electricity Sector in the Emirate of
Abu Dhabi. January 2009. Available online at
http://www.rsb.gov.ae.
Guide to Water Supply Regulations 2009. Issued by:
The Regulation and Supervision Bureau for the Water,
The Healthcare
Provider’s
authorized
EHSMS person
including the
entities EHSMS
Unit and related
entity Facility
Management.
Page 25 of 34
operation or
expansion.
To manage and
control emissions to
ambient air, and
indoor and
occupational air
quality of all the
Healthcare
Provider’s facilities.
The development,
implementation and
maintenance of a
water quality
management system
compliant with
related HAAD
Healthcare Provider
EHSMS standards
including
monitoring and
reporting.



HAAD/HSED/ST/0013/HS_EHSMS
Land Management


HAAD/HSED/ST/0014/HS_EHSMS
Wastewater and Electricity Sector in the Emirate of
Abu Dhabi. January 2009. Available online at
http://www.rsb.gov.ae.
Legionella and the Prevention of Legionellosis. Edited
by: Jamie Bartram et al., World Health Organization,
2007. ISBN 92 4 156297 8.
CDC Guidelines for Environmental Infection Control
in Health-Care Facilities. Recommendations of CDC
and the Healthcare Infection Control Practices
Advisory Committee (HICPAC). MMWR June 6, 2003 /
52(RR10); 1-42.
Technical Guideline-Contaminated Land
Management. Environment Agency Abu Dhabi.
Noise Management


Health Sector EHSMS Requirements - Version 2.1- March 2015
EHSMS Regulatory Framework. Code of Practice 3.0 –
Occupational Noise. Version 2.0, Feb 2012.
WHO Guideline Values for Ambient Noise in Specific
Environments.
ISO 1996-1:2003 - Acoustics - Description,
measurement and assessment of environmental noise
- Part 1: Basic quantities and assessment procedures.
ISO 1996-2:2007 - Acoustics - Description,
measurement and assessment of environmental noise
-- Part 2: Determination of environmental noise
levels.
Page 26 of 34
The Healthcare
Provider’s
authorized
EHSMS person
including the
entities EHSMS
Unit and related
entity Facility
Management.
To manage the
Healthcare
Provider’s facilities
land usage in a
beneficial and
environmentally
responsible way as
to eliminate or
control any
contamination,
emissions and
pollution of land to
a level of ALARP.
The Healthcare
Provider’s
authorized
EHSMS person.
Managing ambient
and occupational
noise resulting from
the Healthcare
Provider’s Facility
activities in
accordance with this
Standard.


HAAD/HSED/ST/0015/HS_EHSMS
Hazardous
Materials
Management




HAAD/HSED/ST/0016/HS_EHSMS
Waste
Management




HAAD/HSED/ST/0017/HS_EHSMS
Infection
Prevention and
Control
Management
Health Sector EHSMS Requirements - Version 2.1- March 2015



EHSMS Regulatory Framework. Code of Practice 1.0 –
Hazardous Materials. Version 2.0, Feb 2012.
United Nations Globally Harmonized System for
Labelling and Classification of Chemicals (GHS);
Joint Commission International Guide for Healthcare
Facilities Management;
UN Recommendations on the Transport of Dangerous
Goods, Model Regulations.
EHSMS Regulatory Framework. Code of Practice 54.0
– Waste Management. Version 2.01, April 2015.
Regulation Concerning Handling of Hazardous
Substances, Hazardous Wastes and Medical Wastes
under Federal Law No. 24 of 1999 for the Protection
and Development of the Environment.
Law No. 21 of 2005 for Waste Management in the
Emirate of Abu Dhabi.
UAE Federal Law No. 6 of 2009, Peaceful Uses of
Nuclear Energy.
Federal Authority for Nuclear Regulation. Regulation
for Radiation Protection and Predisposal Radioactive
Waste Management in Nuclear Facilities (FANR-REG11). Version 0, 20 May 2010.
WHO Manual “Safe Management of Wastes from
Healthcare Activities”, 1999.
HAAD EHSMS Standard 11- Ambient Air Emissions,
Indoor and Occupational Air Quality Management.
HAAD EHSMS Standard 12 - Water Quality.
HAAD EHSMS Standard 16 - Waste Management.
Page 27 of 34
The Healthcare
Provider’s
authorized
EHSMS person
including the
entities EHSMS
Unit and related
entity Facility
Management.
The development
implement and
maintenance of a
Hazardous Materials
Management
Program.
The Healthcare
Provider’s
authorized
EHSMS person
including the
entities EHSMS
Unit and all
identified
personnel.
The development,
implementation and
monitoring of the
Waste Management
Program.
The Healthcare
Provider’s
authorized
EHSMS person
including the
entities EHSMS
Unit, all identified
personnel and
related entity
Manage, prevent
and control any
identified
Healthcare Provider
Facility associated
infectious diseases
and organisms.
Facility
Management.


HAAD/HSED/ST/0018/HS_EHSMS
Smoke-Free
Healthcare
Facilities



HAAD/HSED/ST/0019/HS_EHSMS
Workplace
Wellness
Health Sector EHSMS Requirements - Version 2.1- March 2015

Federal Tobacco Control Law. Law No. 15 of 2009
regarding Tobacco Control.
The World Health Organization (WHO). WHO
Framework Convention on Tobacco Control. Geneva,
Switzerland: WHO Document Production Services;
2005.
HAAD Standard for Smoking Cessation Services
(PHP/PHR/SCS1), June 2010.
Abu Dhabi EHSMS Regulatory Framework, CoP 9.0Workplace Wellness. Version 2.0, Feb 2012.
EHSMS Regulatory Framework. Code of Practice. AD
EHSMS CoP 9.0 –Workplace Wellness. Version 2.0,
Feb 2012.
The Buck Consultants. Working well: a global survey
of health promotion and workplace wellness
strategies. Survey Report. San Francisco, CA, USA;
November 2009.
Page 28 of 34
The Healthcare
Provider’s
authorized
EHSMS person
including the
entities EHSMS
Unit and related
entity Facility
Management.
To manage and
control the use of
tobacco product at
the Healthcare
Provider’s Facilities.
The Authorized
EHSMS person for
HAAD including
the HAAD EHSMS
Unit and related
HAAD Facility
Management.
To actively promote
workplace wellness
in all of the
Healthcare
Provider’s Facility
workplace
environments
through planned
and implemented
workplace wellness
programs and
activities.
Appendix C: Low Risk Entity Checklist
#
1
Criteria
Work Environment/Facility Management
1.1
Workplace is kept clean, orderly and in a sanitary
condition.
1.2
Workplace is maintained in safe conditions.
1.3
Passageways & work areas clear of obstructions.
1.4
Adequate Ventilation
1.5
Adequate Temperature
1.6
Ventilation/air conditioning systems regularly
maintained and regularly inspected
1.7
Lighting is adequate for the operational tasks that being
undertaken.
1.8
General waste containers available & kept clean,
covered, disposed regularly.
1.9
Pest Control Program Maintained
2
2.1
Meets Minimum
Requirements
Yes
No
NA
Ergonomics
Layout and condition of the workspace/station is of an
ergonomic design
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Comments / Remarks
2.2
The chairs used for workstations adjustable
2.3
Filing cabinet drawers kept closed when not in use
3
Electrical Safety
3.1
Power outlets are not overloaded with double adapters
and power boards
3.2
Electrical Cords are safely stowed
3.3
Connectors, plugs and outlet sockets are in a safe
condition
3.4
Electrical equipment and cords are in good conditions
3.5
Access to electrical panels unobstructed
3.6
Electrical panel are secured & locked.
4
Hygiene/Washing Facilities
4.1
Washing facilities are kept in a clean and hygienic
condition. (including cleaning datasheet)
4.2
Washing facilities are well maintained and operational
4.3
Appropriate washing facilities with a supply of clean
hot/cold water, liquid soap and paper towels or other
appropriate mean of drying.
4.4
Floors made of a non-slippery surface.
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Page 30 of 34
5
First Aid
5.1
First Aid Kit easily accessible to each work area, with
necessary supplies available, periodically inspected and
replenished as needed.
5.2
Emergency phone numbers posted
5.3
First Aid Treatment records maintained
6
Fire Protection/Emergency Procedure
6.1
All firefighting tools regularly inspected and maintained
(e.g. fire Extinguisher, Fire hose, etc.)
6.2
Access to firefighting tools clearly marked, visible and
unobstructed.
6.3
Fire exits marked/illuminated and unobstructed
6.4
Employees trained in the proper use of extinguisher &
fire protection procedures
6.5
Assembly Points
7
Personal Protective Equipment
7.1
Appropriate & adequate PPE provided, used and
maintained whenever necessary & required.
7.2
Employees are aware of the proper use of PPE.
7.3
Clean & safe storage of PPE items.
8
Material Storage
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8.1
Large and heavy objects stored on lower shelves
8.2
Storage shelves are not overloaded or beyond their rated
capacity
8.3
No Items are placed on the floor nor reaching the
ceiling.
8.4
Appropriate stepladders or stools to get to materials on
higher shelves
9
Infection Control
9.1
Good hand hygiene and cleaning practices followed.
9.2
Equipment storage, cleaning and disinfection methods
are appropriate for the type of equipment and activity in
the facility.
9.3
Employees received training in infection prevention and
control.
Medical Waste Management procedures followed
9.4
(Handling, segregation, coloured bags/ labelled/ disposal
by Registered ESP…etc.)
10
Safety Signage in Place:
10.1
PPE Requirements
10.2
Hazardous Areas
11
11.1
Appropriate & Adequate Welfare Facilities:
General
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Page 32 of 34
11.2
Eating & Drinking (water)
11.3
Washing/Toilets
11.4
Lighting
11.5
House Keeping
12
Equipment:
12.1
Maintained (Manufacturers Specification)
12.2
Certification/Registers available
12.3
Training & Competencies
12.4
Out of service equipment clearly marked
13
Other Observations:
13.1
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Appendix D: Summary of Implementation Requirements
under the New Risk Classification of Entities
Implementation Requirements
Entity Risk
Ranking
High Risk
Medium
Risk
(SRA will
decide
appropriate
Management
Tool)
Low Risk
Registration
(Form A)
Performance
Reporting
(Form E)
Serious
Incident
Notification
(Form G)
Incident
Investigation
(Form G1)
Full
Management
System
Option 1 – Full
Management
System
Yes
Yes
Yes
Yes (By the
Entity & SRA)
Option 2 –
Mechanism 5
The
mechanism to
be determine
by SRA
No
Yes
Yes ( By the
Entity & SRA)
Checklist
(Appendix C)
tools developed
& implemented
or their
implementation
monitored by the
SRA
No (Only
Register of
Entities by the
SRA is
required)
Yes
Yes (By the
SRA if Fatality
or Serious
Incident is
notified by any
method)
Management
Tool
No

Entities that have been assessed to have High Risk shall (when nominated by the SRA with the
approval of the Center) develop, implement and maintain an operational EHSMS to manage the
EHS hazards and risks of their operations in compliance with AD EHSMS RF, Health Sector
EHSMS Requirements and Standards.

Entities that have been assessed to have Medium Risk shall (based on SRA decision & Center
approval) develop, implement and maintain an operational EHSMS, or Implement current
Mechanism (5).

Entities that have been assessed to have Low Risk shall (after the SRA secures due approvals
from the Center) comply with requirements of AD EHSMS through specific tools (e.g. checklist)
that are developed and implemented or which implemented is monitored by the SRA to ensure
compliance.
© Abu Dhabi OSH Center (OSHAD) 2015
This document is and shall remain the property of the Health Sector/AD OSH Center (OSHAD). The document may only be
used for the purposes for which it was intended. Unauthorised use or reproduction of this document is prohibited.
Health Sector EHSMS Requirements - Version 2.1- March 2015
Page 34 of 34

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