FMS NABH 6th Edition Implementation Guide

Chapter Purpose

FMS protects patients, staff and visitors by controlling facility risk, fire safety, utilities, equipment safety, security, emergency preparedness and construction-related hazards.

Departments Involved

• Engineering
• Maintenance
• Biomedical engineering
• Security
• Housekeeping
• Fire safety team
• Administration
• IPC team
• Quality team

Implementation Responsibilities

• Maintain facility, utilities, equipment and fire-safety controls.
• Assess pre-construction and renovation risk before work starts.
• Keep emergency access, service continuity and safety drills active.
• Close facility-risk observations through owner-wise tracking.

Evidence Categories

• Fire drill records
• Utility maintenance logs
• Equipment maintenance records
• Safety rounds
• PCRA and construction-permit records

Policy/SOP Categories

• Facility safety
• Fire safety
• Utility management
• Equipment maintenance
• Pre-construction risk assessment
• Security

Quality Indicators

• Preventive-maintenance compliance
• Fire-drill completion
• Utility breakdown response time
• Safety-round closure compliance

Internal-audit Questions

• Are fire exits, alarms and extinguishers accessible and checked?
• Are critical utilities maintained and backed up?
• Is renovation assessed for facility and patient risk?
• Are biomedical and facility complaints closed with evidence?

Common Gaps

• Maintenance logs exist but critical-risk prioritisation is weak.
• Construction starts without PCRA or ICRA.
• Fire drills are not scenario-based.
• Utility failures are not reviewed for continuity risk.

Training Topics

• Fire safety
• Utility failure response
• Construction safety
• Equipment safety
• Emergency access management

Practical Implementation Notes

• FMS and IPC should jointly review renovation work because construction can create both facility and infection risk.
• PCRA should be completed before contractors mobilise on site.