Duke University Hospital Utility Management Plan 2013

Purpose: Utilities systems provide essential services that are required by Duke University Health Systems and Duke University Medical Center to support its mission of top-quality patient care, excellence in teaching and advances in research, while utilizing its resources in an efficient and cost effective manner. This document identifies the scope and overall organization of the Utility Management Plan utilized by the Engineering and Operations Department to assure that these essential services are always available. Engineering and Operations reviews the Utility Management Plan on an annual basis for objectives, scope, performance and effectiveness. This annual review is submitted to the DUSC for review and approval. Engineering and Operations provides Utility Management services to Duke University Hospital and Duke Clinics. Engineering and Operations provides Utility Management consultative services, as requested, to community based Duke Clinics, and leased facilities.

Maintenance and Testing of Utility Systems / Components: Drawings, specifications and O&M manuals are kept in the E&O Administration office, the Facility Planning, Design and Construction office, and are available online via secured intranet. System specific manuals and drawings are kept in the associated maintenance shops.

Preventive maintenance and routine maintenance records are kept in the computerized maintenance management system (CMMS). This system provides a variety of reports to assist the managers, foremen, and mechanics in managing, evaluating and improving utility systems. PM tasks are determined and scheduled utilizing recommendations, industry standards, current experiences and evaluations, not to exceed annually. Systems are installed and tested according to the manufacturers recommendations, codes and standards prior to use. Appliances such as computers, microwaves, TVs, coffee pots, copiers, etc. are not part of the Utility Management Program. When purchased, appliances should be UL Listed or have equivalent approval. If appliances do not work properly, have frayed cords, or otherwise appear to be damaged, they should be identified for repair/replacement by the appropriate department. Employees and/or Departments that have questions about the safety or performance of such equipment may contact Engineering and Operations.
Page 1 of 4
S:\2013\January 2013\2013 Utility Management Plan.doc

Duke University Hospital Engineering & Operations

Utilities Management Plan

Inventory: Rather than select utility components for inclusion in the program based on set criteria, Engineering & Operations includes all utilities in the CMMS. The following is a list of systems/components covered by the Utility Management Plan: I. Life Support Systems A. Medical Gas Systems (Air, Oxygen, Nitrous Oxide, Nitrogen, Carbon Dioxide) B. Medical Vacuum Systems C. Emergency Power Supply Systems Infection Control Systems A. Sterilizers and Related Equipment B. Ventilation and exhaust systems, high efficiency and other filtration C. Backflow preventers D. Water treatment Environmental Support Systems A. Air Handling Units B. Exhaust Fans C. Chillers/Chilled Water Systems D. Heat Exchangers E. Cooling Towers F. Plumbing Systems G. Trash and Linen Systems Equipment Support A. Electrical Distribution System B. Pneumatic Tube System C. Elevators / Escalators D. Sprinkler Systems E. Refrigeration Equipment Communication Systems A. Patient Call Systems (Hill Rom call systems are the responsibility of DHTS) B. Fire Alarm Systems C. Building Automation Systems D. Medical Gas Alarm Systems E. Telephone/Paging/Radio Systems (Maintained by OIT/DHTS)

II.

III.

IV.

V.

Page 2 of 4
S:\2013\January 2013\2013 Utility Management Plan.doc

Duke University Hospital Engineering & Operations

Responsibilities:

Utilities Management Plan

The following addresses the primary areas of support as it relates to the Utility Management Plan. Engineering & Operations provides Environment of Care support to these areas. The following summarizes the key responsibilities covered by the plan: I. II. III. IV. V. VI. VII. VIII. Maintain Utility System Component Inventory Insure Maintenance is performed in a timely manner. Promote a safe, controlled, comfortable environment of care. Maintain Utility Systems. Maintain Life Safety Systems. Identification of a maintenance provider for each component and assure this service is provided within an appropriate time period. Provision for emergency repair service on a 24-hour basis. Assess utility failures to minimize occurrences.

Facilities Services Work Group Engineering and Operations actively participates in the Facilities Services Work Group, which provides oversight and guidance to the construction related activities and their impact on patients, visitors, and staff.

Performance Improvement: The Director of Engineering and Operations, along with the department Assistant Directors, is responsible for Performance Improvement, as it relates to the Utility Management Plan. The Assistant Director, E&O Duke Hospital Division, serves on the Duke University Safety Committee representing the department and makes regular reports to the Committee. E&O management participates in the Infection Control Committee, Accreditation Forums, Emergency Management Committee, Hospital operations meetings, and various financial meetings. This is a collaborative effort that provides information, cooperation, and resources to make improvements in the Environment of Care. Specific responsibilities may be delegated to other members of the Engineering and Operations staff as appropriate to assist in developing indicators, data collection systems, reviewing and evaluating data, etc. Some examples of performance monitors include PM Completion Rate, Building Image Rounds, Chart Box Compliance, and Pneumatic Tube System Performance.

Page 3 of 4
S:\2013\January 2013\2013 Utility Management Plan.doc

Duke University Hospital Engineering & Operations

Utilities Management Plan

Utility Failures and Emergencies: The Engineering and Operations Maintenance and Service Guide has specific plans for utility failures and emergencies. This plan is available in all E&O shops and in the Building Automation System Room. Utility / Equipment Failure Reports are compiled and evaluated by E&O. Summaries of these reports are submitted to the DUSC on a monthly basis.

Incident Reporting: Incident reports are completed on situations that resulted in injury or had a significant potential to cause an injury, to patients or visitors. These reports are sent to Risk Management for evaluation. Risk Management sends incident reports that are applicable to the facilities to Engineering and Operations. Engineering and Operations management reviews pertinent reports to identify changes that may be required to prevent a reoccurrence of the situation.

Competency: I. Training A. Engineering & Operations employees go through departmental specific and on-the-job training. 1. Utility systems capabilities, limitations, and special applications. 2. Emergency procedures in the event of system failure. 3. Information and skills necessary to perform assigned maintenance responsibilities. B. Safety training. C. Contractors 1. Individual companies train contractors on basic safety/OSHA issues. 2. Contractors are supervised on hazards specific to Duke. 3. Contractors are given a copy of Duke Contractor Safety Guidebook. Validation A. All maintenance staff members are evaluated annually for performance and job knowledge. B. Certifications C. Licensing

II.

Page 4 of 4
S:\2013\January 2013\2013 Utility Management Plan.doc