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Applies to: Licensed and Nominated Healthcare Providers in the Emirate of Abu Dhabi
Classification: Pulblic
Health Sector EHSMS Requirements
Version 2.1
March 2015
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:
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)
Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 3 of 34
• 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.
Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 4 of 34
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.
Occupational Health and Safety Incident and Consequence Summary for the employee of the entity and
other persons.
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
Increasing
Reporting of
Number of Near Miss & First Near Miss (NM) NM &
3-02
Aid Cases for Contractors First Aid Cases (FA) Decreasing
Trend for FA
by End of
2015
Increasing
Reporting of
Number of Near Miss & First Near Miss (NM) NM &
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
Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 8 of 34
(insert date) 2015
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.
Patients colonized or infected with relevant MDRO (Multi Drug Resistant Organisms)
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
Hazardous Waste Disposal Solid (kg) and Liquid (L) for the previous and
Decreasing
current reporting period Trend/End
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 %)
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
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.
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).
5.2.1 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:
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:
1. Your Name;
1
HAAD Standards on Major Incident and Disaster Preparedness in Healthcare, Ref. Nr. HAAD/HHPS/SD/1.0
Health Sector EHSMS Requirements - Version 2.1- March 2015 Page 17 of 34
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.
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 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.
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)
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.
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)
(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).
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,
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.
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.
2 Ergonomics
3 Electrical Safety
11.1 General
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
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.
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.