Page 1 of 6
Chapter Name: ROM
Version No. : 01 Date : 01.06.2024
Validity :
Apollo Clinic (Licensee of Sanjeevani Health and Document No: ACN/QM/01
Lifestyle Private Limited)
FMS Quality Manual
Chapter-VIII
Facility Management and
Safety (FMS)
Prepared By: Authorized By: Issued By:
Quality Manager Chief Executive Officer Operations Head
Page 2 of 6
Chapter Name: ROM
Version No. : 01 Date : 01.06.2024
Validity :
Apollo Clinic (Licensee of Sanjeevani Health and Document No: ACN/QM/01
Lifestyle Private Limited)
FMS Quality Manual
Original and Master copy. Any hardcopy, printed or photocopied, is considered an uncontrolled copy, unless it is
the original, signed-off version.
Apollo Clinic (A Licensee of Sanjeevani Health and Lifestyle
Private Limited)
The Galleria, 1B, Street Number 124, BG Block, Action Area- I, New Town, Kolkata, West Bengal, 700156
Issue Date: 01.06.2024
Version / Issue No.: 01
Next date of revision: 01.06.2025
Prepared By: Quality Manager:
Authorized By: Administrator:
Issued By: Chief Executive Officer:
Copy Type : Master Copy
Publication, reproduction, photocopying, storage, or transmission electronically or otherwise, of all or any part
of these documents without the prior written permission from Apollo Clinic (New Town) is strictly prohibited. It
is illegal to make copies of all or any part of these documents (whether internally or externally) without the
prior written permission of the owner of the document. For permission regarding the use of all or any part of
the documents, contact Apollo Clinic (New Town).
Prepared By: Authorized By: Issued By:
Quality Manager Chief Executive Officer Operations Head
Page 3 of 6
Chapter Name: ROM
Version No. : 01 Date : 01.06.2024
Validity :
Apollo Clinic (Licensee of Sanjeevani Health and Document No: ACN/QM/01
Lifestyle Private Limited)
FMS Quality Manual
Amendment Record
Sl. Page Clause Date of Amendment Sign of Head-
No. No. /Standard Amendment Made Quality
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FMS.1. The clinic shall operate in an environment which ensures safety of patients, staff and visitors.
Prepared By: Authorized By: Issued By:
Quality Manager Chief Executive Officer Operations Head
Page 4 of 6
Chapter Name: ROM
Version No. : 01 Date : 01.06.2024
Validity :
Apollo Clinic (Licensee of Sanjeevani Health and Document No: ACN/QM/01
Lifestyle Private Limited)
FMS Quality Manual
a. Updated drawings are maintained with details of site layout, floor plans and fire escape routes.
At ACN there are drawings which are as per the approved plan, the drawings help in repair and
maintenance works.
In addition to fire evacuation plans, there are separate civil, electrical, plumbing, HVAC and piped medical
gas drawings are also maintained.
The policy on drawings is defined and documented in (ACN/FMS/RD/01).
b. There are internal and external sign posting in the Clinic in a language understood by patient,
families and community.
At ACN there are signages to guide patients and visitors. Statutory requirements are also met. It is also
kept in mind that signages are made in bilingual format i.e. English & Bengali. The signages are prominently
displayed in appropriate locations clearly visible to all.
Fire signage follows the norms laid down by National Building Code and/or respective statutory body (for
example, fire service). There are also warning signages outside the room with laser equipment, X-ray
radiation, strong magnetic field etc.
c. Facilities and space provisions are appropriate to the scope of clinic.
At ACN the facilities provided are as per best practices/ national /international guidelines and
commensurate with the scope of the services offered.
Adequate space are provided keeping patient safety and ease of providing clinical care in mind.
For adequacy of space, the IPHS standards and various international standards, government directives
from agencies like AERB guidelines for radiation equipment, etc. are considered as reference.
d. Patient safety devices and infrastructure are installed across the clinic.
The clinic is made in such a way so that it can easily accessible to receive and manage non- ambulatory
patients and differently abled persons.
Patient-safety devices includes grab bars, bed rails, sign posting, safety belts on stretchers and wheelchairs,
alarms both visual and auditory where applicable, warning signs like radiation or biohazard, call bells, fire-
safety devices, etc.
FMS.2. The clinic has a programme for equipment and facility management.
a. The clinic plans for equipment in accordance with its services and strategic plan.
At ACN there is an equipment plan which is implemented in a phased manner and also take into
consideration the future requirements. It includes list of equipment available at the clinic, expected life
span, equipment serial no, location and maintenance schedule, etc. The future requirement in terms of
Prepared By: Authorized By: Issued By:
Quality Manager Chief Executive Officer Operations Head
Page 5 of 6
Chapter Name: ROM
Version No. : 01 Date : 01.06.2024
Validity :
Apollo Clinic (Licensee of Sanjeevani Health and Document No: ACN/QM/01
Lifestyle Private Limited)
FMS Quality Manual
number of existing equipment and new equipment along with their expected timelines are also the part
of the plan. Written guidance also supports medical equipment replacement and disposal.
b. Equipment is periodically inspected and calibrated for their proper functioning.
The periodicity for inspection and calibration for each equipment could vary, but shall be defined. A
unique identification is provided to each equipment. The operator shall be trained in handling the
equipment.
The maintenance plan should be considered based on manufacturer's recommendations and past
maintenance history.
There shall be a mechanism for addressing the breakdowns along with monitoring of the turnaround time
for repairs.
There shall be a planned preventive maintenance tracker. The clinic either calibrates the utility equipment
in-house or outsources, maintaining traceability to national or international or manufacturer's guidelines /
standards.
Examples could include pressure gauges of steam sterilizer, temperature monitoring devices of
refrigerators used for storage of medicine etc.
c. Safe water and uninterrupted electrical supply is available.
The organization made arrangements for sufficient supply of adequate potable water. The quality of
potable water is monitored at last once in six months or more frequently and documented.
For water quality, ISO 10500:2012 standard is followed.
In case of a shortfall in water or electricity, alternate sources are there to manage the shortfall.
To estimate the water requirement the National Building Code is taken as reference. Alternate water
supply includes underground reservoir & municipal tanker facility. Alternate electric supply is there in
terms of DG sets & UPS.
d. Written guidance governs procurement, handling, storage, distribution, usage and replenishment
of medical gases.
The clinic adheres to statutory requirements.
It follows a uniform colour coding system as per ISO standards. Proper signage is kept for used, full and
empty cylinders respectively.
Appropriate safety measures are developed and implemented for all levels, including alarm units and valve
boxes installation at various locations, as applicable.
Alternate sources for medical gases, vacuum and compressed air are provided for, in case of failure.
There is a maintenance plan for piped medical gas, compressed air and vacuum installation.
Prepared By: Authorized By: Issued By:
Quality Manager Chief Executive Officer Operations Head
Page 6 of 6
Chapter Name: ROM
Version No. : 01 Date : 01.06.2024
Validity :
Apollo Clinic (Licensee of Sanjeevani Health and Document No: ACN/QM/01
Lifestyle Private Limited)
FMS Quality Manual
FMS.3. The clinic has plans for emergencies (fire and non-fire) and hazardous materials within the
facility.
a. The clinic has plans and provisions for early detection, abatement and containment of fire and
non-fire emergencies.
The clinic has a fire plan covering fire arising out of burning of inflammable items, explosion, electric short
circuiting etc., including deployment of fire-fighting equipment. Training plan and schedule for conducting
mock drills (at least twice a year), is available. Outcome of these mock drills with the scope of
improvement is also documented.
Fire-exit plan is displayed on each floor of the clinic. Exit doors are identified with adequate signages are
used to locate them.
There is a maintenance plan for fire-related equipment and infrastructure. The organization conducts
electrical safety audit for the clinic periodically.
Non-fire emergencies include but not be limited to floods, earthquake, anti- social behavior by
patients/relatives, terrorist attacks etc. depending upon the location of the clinic.
b. The staff is trained for their role in case of such emergencies.
In case of fire, the roles of each designated person are well defined.
The training includes various classes of fire, information and demonstration on how to use a fire
extinguisher and the procedure to be followed in case of fire emergencies. The process of evacuation for
patient and staff is an integral part of training.
Staff training also includes non-fire emergencies.
c. The clinic has addressed identification, sorting, storage, handling, transportation, disposal
mechanism, and method for managing spillages of hazardous materials.
The clinic identifies, lists and documents the hazardous materials and has a documented procedure for
their sorting, storage, handling, transportations, disposal mechanism, and method for managing spillages
and adequate training of the personnel for these jobs.
The clinic takes all necessary steps to eliminate or reduce hazards and associated risks.
Material Safety Data Sheets (MSDS) for all hazardous materials are available and personnel who handle
such materials are appropriately trained.
There is a plan for managing spills of hazardous materials, including availability of HAZMAT kit(s).
Prepared By: Authorized By: Issued By:
Quality Manager Chief Executive Officer Operations Head
