Health Sector EHSMS - 9!12!2015

Health Authority – Abu Dhabi
Document Title: Health Sector EHSMS Requirements Version 2.1

Document Ref.
HAAD/EHSMS/ST/0000/HS_EHSMS/V2.1 Version: 2.1
Number:
Effective
Approval Date: 08 June 2015 June 2015
Date:
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

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)
• 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.
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.

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  Sum of KPI 2-02, 3-01 & 4-01 Reduce (5%)

Total OHS Incidents by end of
2015
Occupational Health and Safety Performance for Entity - Compulsory Reporting to Health Sector Authority
 Lost Time Injuries
 Restricted Workday Case
 Medical Treatment Case
Total OHS Incidents /  Total Injuries & Illness for calculating KPI 2-
2-02 Reduce (5%)
Consequences for employees 03 (TRCF) by end of
 Total Lost Workdays for calculating KPI 2-04 2015
(LTISR)
 Serious Dangerous Occurrence
 Equipment/Property Damage
 Number of Total Injuries & illness Reported
Total Reportable Case in the Reporting Period Reduce (5%)
2-03 by end of
Frequency (TRCF)  Number of working Hours in Reporting 2015
Period
 Number of Workdays lost due to Injuries &
Lost Time Injury Severity Rate Illness in the Reporting Period Reduce (5%)
2-04 by end of
(LTISR)  Number of working Hours in Reporting 2015
Period
 Number of Lost Time Injuries in the
Lost Time Injury Frequency Reporting Period Reduce (5%)
2-05
Rate (LTIFR)  Number of Working Hours in Reporting by end of
2015
Period
Increasing
Reporting of
Number of Near Miss & First  Near Miss (NM) NM &
2-06
Aid Cases for employees  First Aid Cases (FA) Decreasing
Trend for FA
by End of
2015

 Lost Time Injuries
 Restricted Workday Case Reduce (5%)
Total Incidents/Consequence by end of
3-01  Medical Treatment Case 2015
for Contractors
 Serious Dangerous Occurrence
 Equipment/Property Damage
Increasing
Reporting of
3-02
Aid Cases for Contractors  First Aid Cases (FA) Decreasing
Trend for FA
by End of
2015
 Total No. of Contractors

 Review/Approval of Contractors EHS
Procedures
Number of Monitoring  Specific Requirement/Part System Audit
Activities Performed on Performed on Contractors Increasing
3-03
Contractors/Supply chain by  Full EHSMS Audit Performed on Contractor Trend/End of
Entity 2015
 Inspection Performed on Contractors
 Contractor Incidents Investigation by Entity
 Corrective Notices Issued to Contractors
 Breach Notices Issued to Contractors
Number of Fatalities & Injuries  Fatalities Decreasing

4-01
for other Persons  Other Injuries Trend/End of
2015
Increasing
Reporting of
4-02
Aid Cases for other Persons  First Aid (FA) Decreasing
Trend for FA
by End of
2015
 Number of Employees in EHS Department
 Number of UAE Nationals in EHS
Department
5-01 EHS Department Resources  % of UAE nationals in EHS Department Increasing
 Number of Employees attended the AD Trend/End of
2015
EHSMS Practitioner Course
 Number of Employees Registered at
Qudorat.
Average no. of training hours  Total no. of EHS training hours undertaken Increase (5%)
5-02
per employee by employees by end of
2015
Third Party EHSMS  3rd Party EHSMS Compliance Audit
5-03 conducted & Audit Report submitted to SRA Increasing
Compliance Audit Trend/End of
 EHSMS Compliance Audit is scheduled for
(insert date) 2015
 Number of warning notice received

Number of Corrective Notices  Decreasing
5-04 Number of Improvement notice received Trend/End of
 Number of Prohibition notice received 2015
 Number of Fines received
 Number of enforceable undertakings Decreasing
5-05 Number of Breach Notice Trend/End of
 Total value of all fines. Penalties/ 2015
enforceable undertakings enforced (AED)
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.

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
For at least one commonly performed or

important surgical procedure in the reporting Decreasing
Trend/End
period: of 2016
HAI-01 SSI - Surgical Site Infections  Number of surgical procedures performed
 Number of surgical site infections
 Incidence rate of surgical site infections per
100 surgical procedures performed
Device-associated Healthcare-associated infections
For ICU patients only, in the reporting period:

 Number of ventilator-days Decreasing
Trend/End
Ventilator-associated Pneumonia  Number of cases with suspected or of 2016
HAI-02
(VAP) 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: Decreasing
Trend/End
 Number of central line catheter days of 2016
Central-line-associated blood
HAI-03  Number of cases with suspected or
stream infection (CLABSI)
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: Decreasing
Trend/End
 Number of urinary tract catheter days of 2016
Catheter-associated Urinary Tract  Number of cases with suspected or
HAI-04
Infection (CAUTI) 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
Other healthcare-associated Decreasing
o Healthcare-associated blood borne
HAI-05 infections and outbreaks (Other Trend/End
infections (HIV/AIDS, Hepatitis B, of 2016
HAI)
Hepatitis C)
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)
 Number of patients colonized or infected

MDRO- Methicillin-resistant with MRSA in the reporting period Decreasing
01 Staphylococcus aureus (MRSA) Trend/End
of 2016
MDRO- with Clostridium difficile in the reporting Decreasing
Clostridium difficile (CDIFF) Trend/End
02 period of 2016
MDRO- Vancomycin-resistant with VRE in the reporting period Decreasing
03 Enterococci (VRE) Trend/End
of 2016
Extended spectrum beta-  Number of patients colonized or infected
MDRO- with ESBL in the reporting period Decreasing
lactamase producing Escherichia Trend/End
04
coli and Klebsiella spp. (ESBL) of 2016
Number of patients colonized or infected with
Multi-drug/extended drug Decreasing
MDRO-  MDR-TB
resistant Mycobacterium Trend/End
05  XDR-TB of 2016
tuberculosis (MDR/XDR-TB)
in the reporting period
Antibiotic Resistance Surveillance
See HAAD EHSMS Standard for HealthCare

AR-01 Staphylococcus aureus Providers-Monitoring and Reporting of Decreasing
Trend/End
Antimicrobial Resistance of 2016
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

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
Increasing
 Number of air quality monitoring tests Trend/End
conducted in the reporting period of 2016
EM-01 Air Quality Monitoring  Number of air quality monitoring test Decreasing
results exceeding the acceptable limits of Trend/End
the HAAD EHSMS Standard 11 – Air Quality of 2016
Standard
 Number of water quality monitoring tests Increasing
conducted in the reporting period Trend/End
of 2016
 Number of water quality monitoring test Decreasing
EM-02 Water Quality Monitoring results exceeding the acceptable limits of Trend/End
the HAAD EHSMS Standard 12 – Water of 2016
Quality Standard

Environmental KPIs
Power Consumption  Total kW h and kW h Per Employee for the

previous and current reporting period Decreasing
E-01 (Total Kilowatts Hours (kW h) and Trend/End
 Percentage Reduction or Increase (Indicate of 2015
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 Reduce (5%)
Water use (in production by end of
E-02 processes, office activities)  Percentage Reduction or Increase (Indicate 2015
(Total cubic meters (m3) and m3
per Employee)
Paper Consumption  Average No. of Pages used per Employee for
the previous and current reporting period Reduce (5%)
E-03 Average number of paper pages by end of
used per employee per month  Percentage Reduction or Increase (Indicate 2015
 Number of vehicles owned and/or operated
Fuel Consumption by entity for the previous and current Decreasing
Trend/End
Average fuel consumption of reporting period of 2015
entity owned and /or operated  Average fuel consumption of vehicles
E-04
vehicles. (Combined Cycle L/100 km) for the
previous and current reporting period
(Liters per 100 kilometers)  Percentage Reduction or Increase (Indicate
Non-Hazardous Waste Disposal  Solid (kg) and Liquid (L) for the previous and
current reporting period Decreasing
Amount of non-hazardous (solid Trend/End
E-05  Percentage Reduction or Increase for both of 2015
and liquid) waste collected by Solid (kg) and Liquid (L)(Indicate reduction
Service Providers for disposal.
as a negative figure e.g. –3.5 %)
Non-Hazardous Waste Recycling  Solid (kg) and Liquid (L) for the previous and
Increasing
current reporting period Trend/End
Amount of segregated non-
hazardous (solid and liquid)  Percentage Reduction or Increase for both of 2015
E-06
waste collected by Service Solid (kg) and Liquid (L) (Indicate reduction
Providers for recycling / reuse / as a negative figure e.g. –3.5 %)
further processing.
Hazardous Waste Disposal  Solid (kg) and Liquid (L) for the previous and
Decreasing
E-07 Amount of hazardous (solid and  Percentage Reduction or Increase for both of 2015
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 Recycling  Solid (kg) and Liquid (L) for the previous and
Increasing
Amount of hazardous (solid and
of 2015
E-08 liquid) waste collected by Service  Percentage Reduction or Increase for both
Providers for recycling / reuse / Solid (kg) and Liquid (L) (Indicate reduction
further processing. as a negative figure e.g. –3.5 %)
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.

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).

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 opscenter@haad.ae
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.);

 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.
5.2.5 Duties arising during Emergencies
 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.
5.3 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: opscenter@haad.ae ,
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
2. Your Exact Location;
3. Nature of Incident or Emergency; and
4. Service/ Help Required and Repeat The Message Again.
 Third: Health Sector EHSMS Section by completing and sending Form G “Incident Notification
Form” via email: ehsms@haad.ae 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.
5.4 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.

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 x to cover AD EHSMS RF
and HS EHSMS Requirements
+ Standards
High 1 Minimum 1
&
Min. of 3 x for high risk
activities and departments
1 x to cover AD EHSMS RF
and HS EHSMS Requirements
Medium + Standards
1 Minimum 1
(Full EHSMS System) &
Min. 3 x for high risk activities
and departments
Medium
Not Required 0 0
(Mechanism 5)
Low Not Required 0 0
EHS Audit Frequencies per Entity Risk per year

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

Entity Risk / HS SRA HS SRA
Internal
Inspection Type (Random) (Planned)
High Risk Based 1 Minimum 1
Medium
Risk Based 1 1
(Full EHSMS System)
Medium
Risk Based As required 1
(Mechanism 5)
Risk Based
Low As required 1
(minimum of 2 times)
EHS Inspection Frequencies per Entity Risk per year

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.

HAAD Health Sector EHSMS List of Violations and Penalties
Penalty -
Penalty - First Penalty - Second Penalty - Third
No. Violation/complaint Fourth
Infraction Infraction Infraction
Infraction
Failure to register with HAAD
1 for development of EHSMS by
date notified
Failure to Amend Entity
Information and/or Authorized
2
EHSMS contact person details
and keep up to date
Failure to commence
3 development of entity EHSMS
by dates notified
Failure to submit EHSMS
4 documentation for Review and
Approval by dates notified
Failure to commence
5 implementation of entity
EHSMS by dates notified
Failure to notify HAAD of Temporary
Warning to the Warning to the Warning to the
implementation of EHSMS and suspension of
6 Facility Facility Facility
submit declaration of Facility
Owner/Manager Owner/Manager Owner/Manager
Implementation license
Failure to submit incident
report and/or in time frames
7
specified and/or with details
required
Failure to submit incident
investigation report and/or in
8
time frames specified and/or
with details required
Failure to submit quarterly
report and/or in time frames
9
specified and/or with details
required
Failure to submit annual third
party report and/or in time
10
frames specified and/or with
details required
Warning, and Warning, and Warning, and
improvement or improvement or improvement or Temporary
Failure to comply with HAAD
prohibition prohibition prohibition suspension or
11 EHSMS Requirements and
notice to the notice to the notice to the withdrawal of
standards per violation.
facility facility Owner/ facility Owner/ facility license
Owner/Manager Manager Manager
(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).

Appendix A: Outline of Entity Emergency Management Plans
1.0 Policy Statement
2.0 Purpose and Scope
3.0 Pre-Emergency Planning
3.1 Hazard Identification
3.2 Risk Analysis
3.3 EHS Management System and Standards Requirements
3.4 Emergency Organization Responsibilities
3.5 Resources and Training
3.6 Internal Alerting
3.7 External Alerting
3.8 Communications
3.9 Public Affairs
4.0 Emergency Response
4.1 Response Action Decision Making
4.2 Plan Activation and Response/Communications Mobilization
4.3 Response Action/Containment/Isolation/Quarantine/Clean-up
4.4 Emergency Operations Centre and Liaison
4.5 Evacuation and Accountability
4.6 Management of Contaminants and Debris
4.7 Site Restoration/Remediation
4.8 Incident Investigation, Debriefing and Post-Incident Evaluation
4.9 Reporting (Internal and to HAAD)
5.0 Training and Practice Drills
5.1 Training records
5.2 Practice Drills summary reports
6.0 Plan Evaluation Reports
7.0 Plan Updates
8.0 Appendices and Operational Guidelines

Appendix B: Health Sector Legal and Regulatory Requirements
Standard reference number HAAD Healthcare Legal Reference Responsible Specific action
Providers EHSMS Person/ Entity
Standard Name
Decree No. (42) of 2009 Concerning AD EHSMS
AD EHSMS Regulatory Framework (Version 02/2012)
 The Abu Dhabi EHSMS Regulatory Framework, The Healthcare Analysing and
Elements 06 – Emergency Management, Version 2.0, Provider’s developing an
Feb 2012. authorized emergency plan for
 The Abu Dhabi EHSMS Regulatory Framework, Code EHSMS person the Healthcare
of Practice 6.0 – Emergency Management, Version including the Provider’s facilities,
2.0, Feb 2012.
entities EHSMS accompanying
 HAAD Standards for Reporting of Public Health
Statistics (HAAD/PHST/SD/VIPCD/1.2), August 2013; Unit and all letters of
Emergency  HAAD EHSMS Standard 0017 – Infection Prevention identified appointment and
HAAD/HSED/ST/0006/HS_EHSMS personnel, fire incident reporting
Management and Control Management;
 HAAD Standards for Major Incident and Disaster marshals and first structure.
Preparedness in Healthcare (HAAD/HHPS/SD/1.0); aiders.
 HAAD Guidelines for Health Facility Design, Approvals,
Construction and Consultant Prequalification. Part C –
Access, Mobility, OHS and Security. Version 2,
07/09/2010.
 Federal Environmental Law No. (24) or 1999 for the The Healthcare Conduct a
Protection and Development of the Environment; Provider’s systematic
 Technical Guidance Document for Submission of authorized Environmental,
Environmental Impact Assessment Report – 2009. EHSMS person Health and Safety
Environmental, including the Impact Assessment
Health and Safety entities EHSMS (EHSIA) for projects
HAAD/HSED/ST/0007/HS_EHSMS
Impact Unit. and/or Healthcare
Assessments Provider facilities
before any
significant
construction,
modification,

operation or
expansion.
 The Abu Dhabi EHSMS Regulatory Framework. Code The Healthcare To manage and
of Practice. AD EHSMS CoP 52- Local Exhaust Provider’s control emissions to
Ventilation. Version2.0, Feb 2012. authorized ambient air, and
 The Abu Dhabi EHSMS Regulatory Framework - EHSMS person indoor and
Technical Guideline Occupational Air Quality, Version including the occupational air
2.0, Feb 2012. entities EHSMS quality of all the
 ASHRAE Standard 170-2008: Ventilation of Health Unit and related Healthcare
Care Facilities. entity Facility Provider’s facilities.
Ambient Air http://www.ashrae.org/. Management.
Emissions, Indoor  ASHRAE Standard 62.1-2007: Ventilation for
Air and Acceptable Indoor Air Quality.
HAAD/HSED/ST/0011/HS_EHSMS
Occupational Air http://www.ashrae.org/.
Quality  HAAD Facilities EHSMS Standard 0017 – Infection
Management 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 Water Quality Regulations 2009. Issued by: The The Healthcare The development,
Regulation and Supervision Bureau for the Water, Provider’s implementation and
Wastewater and Electricity Sector in the Emirate of authorized maintenance of a
Abu Dhabi. July 2009. Available online at EHSMS person water quality
http://www.rsb.gov.ae. including the management system
 The Water Supply Regulations 2009. Issued by: The entities EHSMS compliant with
HAAD/HSED/ST/0012/HS_EHSMS Water Quality Unit and related related HAAD
Regulation and Supervision Bureau for the Water,
Wastewater and Electricity Sector in the Emirate of entity Facility Healthcare Provider
Abu Dhabi. January 2009. Available online at Management. EHSMS standards
http://www.rsb.gov.ae. including
 Guide to Water Supply Regulations 2009. Issued by: monitoring and
The Regulation and Supervision Bureau for the Water, reporting.

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 The Healthcare To manage the
Management. Environment Agency Abu Dhabi. Provider’s Healthcare
authorized Provider’s facilities
EHSMS person land usage in a
including the beneficial and
entities EHSMS environmentally
HAAD/HSED/ST/0013/HS_EHSMS Land Management Unit and related responsible way as
entity Facility to eliminate or
Management. control any
contamination,
emissions and
pollution of land to
a level of ALARP.
 EHSMS Regulatory Framework. Code of Practice 3.0 – The Healthcare Managing ambient
Occupational Noise. Version 2.0, Feb 2012. Provider’s and occupational
 WHO Guideline Values for Ambient Noise in Specific authorized noise resulting from
Environments. EHSMS person. the Healthcare
 ISO 1996-1:2003 - Acoustics - Description, Provider’s Facility
HAAD/HSED/ST/0014/HS_EHSMS Noise Management measurement and assessment of environmental noise activities in
- Part 1: Basic quantities and assessment procedures. accordance with this
 ISO 1996-2:2007 - Acoustics - Description, Standard.
measurement and assessment of environmental noise
-- Part 2: Determination of environmental noise
levels.

 EHSMS Regulatory Framework. Code of Practice 1.0 – The Healthcare The development
Hazardous Materials. Version 2.0, Feb 2012. Provider’s implement and
 United Nations Globally Harmonized System for authorized maintenance of a
Hazardous Labelling and Classification of Chemicals (GHS); EHSMS person Hazardous Materials
HAAD/HSED/ST/0015/HS_EHSMS Materials  Joint Commission International Guide for Healthcare including the Management
Management Facilities Management; entities EHSMS Program.
 UN Recommendations on the Transport of Dangerous Unit and related
Goods, Model Regulations. entity Facility
Management.
The Healthcare The development,

 EHSMS Regulatory Framework. Code of Practice 54.0 Provider’s implementation and
– Waste Management. Version 2.01, April 2015. authorized monitoring of the
 Regulation Concerning Handling of Hazardous EHSMS person Waste Management
Substances, Hazardous Wastes and Medical Wastes including the Program.
under Federal Law No. 24 of 1999 for the Protection entities EHSMS
and Development of the Environment. Unit and all
 Law No. 21 of 2005 for Waste Management in the identified
Waste personnel.
HAAD/HSED/ST/0016/HS_EHSMS Emirate of Abu Dhabi.
Management
 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-REG-
11). Version 0, 20 May 2010.
 WHO Manual “Safe Management of Wastes from
Healthcare Activities”, 1999.
The Healthcare Manage, prevent
Provider’s and control any
 HAAD EHSMS Standard 11- Ambient Air Emissions, authorized identified
Infection
Indoor and Occupational Air Quality Management. EHSMS person Healthcare Provider
Prevention and
HAAD/HSED/ST/0017/HS_EHSMS  HAAD EHSMS Standard 12 - Water Quality. including the Facility associated
Control
 HAAD EHSMS Standard 16 - Waste Management. entities EHSMS infectious diseases
Management
Unit, all identified and organisms.
personnel and
related entity

Facility
Management.
 Federal Tobacco Control Law. Law No. 15 of 2009 The Healthcare To manage and
regarding Tobacco Control. Provider’s control the use of
 The World Health Organization (WHO). WHO authorized tobacco product at
Framework Convention on Tobacco Control. Geneva, EHSMS person the Healthcare
Smoke-Free including the Provider’s Facilities.
Switzerland: WHO Document Production Services;
HAAD/HSED/ST/0018/HS_EHSMS Healthcare entities EHSMS
2005.
Facilities Unit and related
 HAAD Standard for Smoking Cessation Services
(PHP/PHR/SCS1), June 2010. entity Facility
 Abu Dhabi EHSMS Regulatory Framework, CoP 9.0- Management.
Workplace Wellness. Version 2.0, Feb 2012.
The Authorized To actively promote
EHSMS person for workplace wellness
HAAD including in all of the
 EHSMS Regulatory Framework. Code of Practice. AD the HAAD EHSMS Healthcare
EHSMS CoP 9.0 –Workplace Wellness. Version 2.0, Unit and related Provider’s Facility
Feb 2012. HAAD Facility workplace
Workplace
HAAD/HSED/ST/0019/HS_EHSMS  The Buck Consultants. Working well: a global survey Management. environments
Wellness
of health promotion and workplace wellness through planned
strategies. Survey Report. San Francisco, CA, USA; and implemented
November 2009. workplace wellness
programs and
activities.

Appendix C: Low Risk Entity Checklist
Meets Minimum
# Criteria Requirements Comments / Remarks
Yes No NA
1 Work Environment/Facility Management
Workplace is kept clean, orderly and in a sanitary
1.1
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
Ventilation/air conditioning systems regularly
1.6
maintained and regularly inspected
Lighting is adequate for the operational tasks that being
1.7
undertaken.
General waste containers available & kept clean,
1.8
covered, disposed regularly.
1.9 Pest Control Program Maintained
2 Ergonomics
2.1 Layout and condition of the workspace/station is of an

ergonomic design

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

Appropriate washing facilities with a supply of clean
4.3 hot/cold water, liquid soap and paper towels or other
appropriate mean of drying.
4.4 Floors made of a non-slippery surface.

5 First Aid
First Aid Kit easily accessible to each work area, with
5.1 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

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.
Equipment storage, cleaning and disinfection methods
9.2 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 Appropriate & Adequate Welfare Facilities:
11.1 General

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

Appendix D: Summary of Implementation Requirements
under the New Risk Classification of Entities
Implementation Requirements
Entity Risk Management Serious
Performance Incident
Ranking Tool Registration Incident
Reporting Investigation
(Form A) Notification
(Form E) (Form G1)
(Form G)
Full
High Risk Management
System Yes (By the
Yes Yes Yes
Medium Option 1 – Full Entity & SRA)
Risk Management
(SRA will System
decide The
appropriate Option 2 – mechanism to Yes ( By the
No Yes
Management Mechanism 5 be determine Entity & SRA)
Tool) by SRA
Checklist
(Appendix C) Yes (By the
No (Only
tools developed SRA if Fatality
Register of
& implemented or Serious
Low Risk or their
Entities by the No Yes
Incident is
SRA is
implementation notified by any
required)
monitored by the method)
SRA
 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.

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Health Authority – Abu Dhabi

Document Title: Health Sector EHSMS Requirements Version 2.1

Last reviewed Date: May 2015 Next Review: June 2016

Revision History: Version 1 issued July 2011

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 1 of 34

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 2 of 34

 Health Sector OHS Policy;

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 5 of 34

KPI Description What should be reported? Target or

Abu Dhabi OHS Mandated KPI’s

2-01  Sum of KPI 2-02, 3-01 & 4-01 Reduce (5%)

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 7 of 34

 Total No. of Contractors

Number of Fatalities & Injuries  Fatalities Decreasing

 Number of warning notice received

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 9 of 34

KPI Description What should be reported? Target or

Health Sector Specific EHSMS KPI’s

Procedure-associated Healthcare-associated infections

For at least one commonly performed or

Device-associated Healthcare-associated infections

For ICU patients only, in the reporting period:

 Number of patients colonized or infected

Antibiotic Resistance Surveillance

See HAAD EHSMS Standard for HealthCare

AR-02 Streptococcus pneumonia Decreasing

AR-03 Enterococcus faecalis Decreasing

AR-04 Enterococcus faecium Decreasing

AR-05 Escherichia coli Decreasing

AR-06 Klebsiella spp. Decreasing

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 11 of 34

AR-08 Shigella spp. Decreasing

AR-09 Pseudomonas aeruginosa Decreasing

AR-10 Acinetobacter baumannii Decreasing

AR-11 Stenotrophomonas maltophilia Decreasing

AR-12 Neisseria gonorrhoeae Decreasing

AR-13 Mycobacterium tuberculosis Decreasing

AR-14 Candida albicans Decreasing

Workplace Environment Monitoring Results

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 12 of 34

Power Consumption  Total kW h and kW h Per Employee for the

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 13 of 34

Additional Health Sector-specific KPIs to monitor performance of Nominated Entities with

 Frequency and incidence rates of relevant Healthcare-associated infections

 Frequency of colonization and infection of patients with Multi-Drug Resistant Organisms

 Trends of environmental KPIs

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 14 of 34

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 15 of 34

 Provide guidance, support, assistance and directions as requested, reasonable,

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 16 of 34

5.2.5 Duties arising during Emergencies

 In the event of an emergency, healthcare providers, blood banks, mortuaries, vaccination

5.3 Health Sector Emergency Communications with Stakeholders, local Authorities

5.3.1 Sector Communication

 First: Local Emergency Services by dialling (999)

When transmitting a message by telephone, or by any other means of communication always

6. Health Sector Audit and Inspection Program

6.1 Sector EHS Audit Categories:

Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 18 of 34

Health Sector Regulatory Authority (SRA) audits:

6.1.1 Sector EHS Annual Audit Frequencies

Entity Risk / Audit Type Internal External HS SRA

Low Not Required 0 0