Facility management and safety
Assesses hospital governance, standardized clinical protocols, staff adherence, and documented evidentiary compliance for facility management and safety.
Trend Direction
up (+3%)
Identified compliance findings in FMS (8)
Fire exit on level 3 obstructed by stored equipment during walkthrough.
Several equipment calibration labels expired; CMMS records not reconciled with floor inventory.
Evidence gap identified for FMS.4 during learner evaluation; requires documented remediation. (demonstration)
Evidence gap identified for FMS.4 during live field capture; requires documented remediation. (demonstration)
Evidence gap identified for FMS.8 during self-assessment; requires documented remediation. (demonstration)
Evidence gap identified for FMS.8 during mock surveyor; requires documented remediation. (demonstration)
Evidence gap identified for FMS.4 during live field capture; requires documented remediation. (demonstration)
Evidence gap identified for FMS.8 during document analysis; requires documented remediation. (demonstration)
Requirements & Measurable Elements
19 total requirementsRequirement | Standard text (paraphrased) | Criticality | Measurable Elements | Status |
|---|---|---|---|---|
| FMS.4 | Fire and life-safety programme with maintained egress (paraphrased) policydrillobservation | critical | 2 of 3 met66% | Partial |
| FMS.7 | Fire-fighting equipment inspected and unobstructed (paraphrased) inspectionobservation | high | 3 of 5 met62% | Gap |
| FMS.8 | Medical equipment inspected, tested and maintained (paraphrased) cmmslogs | high | 2 of 3 met70% | Partial |
| FMS.5 | Facility management and safety — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met75% | Partial |
| FMS.6 | Facility management and safety — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met66% | Partial |
| FMS.7 | Facility management and safety — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 6 met64% | Gap |
| FMS.8 | Facility management and safety — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 6 met53% | Gap |
| FMS.9 | Facility management and safety — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met61% | Gap |
| FMS.10 | Facility management and safety — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met82% | Partial |
| FMS.11 | Facility management and safety — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 4 met69% | Partial |
| FMS.12 | Facility management and safety — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 5 of 6 met80% | Partial |
| FMS.13 | Facility management and safety — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met79% | Partial |
| FMS.14 | Facility management and safety — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met56% | Gap |
| FMS.15 | Facility management and safety — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 4 of 6 met64% | Gap |
| FMS.16 | Facility management and safety — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 3 of 4 met82% | Partial |
| FMS.17 | Facility management and safety — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 4 met62% | Gap |
| FMS.18 | Facility management and safety — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met67% | Partial |
| FMS.19 | Facility management and safety — control 19: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met80% | Partial |
| FMS.20 | Facility management and safety — control 20: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met55% | Gap |