ESTATE MANAGEMENT
Each Operations Manual should be structured to include the following essential sections:
1: Escalation Pathways and Emergency Response Procedures
This section clearly defines protocols for escalation and emergency responses. The importance of being prepared for emergencies or plant failures is also highlighted in HBN 00-07: Planning for a resilient healthcare system. This document says “Robust procedures should be prepared and tested for the following priority incidents…”3 It should detail the chain of command, contact information for key personnel, and specific actions to be taken during various emergency scenarios. ECP and FCP documents should also include this information (although this might be in a different format).
2: Policy All relevant policies, which would be kept up to date, to ensure that all team members are informed and aligned with institutional and regulatory expectations. This is particularly helpful in the event of audit, as team members have the policy to hand to call upon and refer to.
3: General procedures Procedures and Standard Operating Procedures (SOPs) for routine (such as filter changes on an AHU, or cylinder changes on a medical gas manifold) and critical tasks (for example, changing over a VIE in the event of an Oxygen supply failure). These should be detailed and regularly updated to reflect best practices and any changes to equipment or methodology. Maintenance or task-based SOPs should be attached to job requisitions, be it planned or reactive, so that Estates teams may choose to centralise only key procedures to avoid unnecessary maintenance of the manuals.
4: Asset List An exhaustive inventory of all assets managed by the Estates & Facilities team – including equipment specifications, maintenance schedules, and lifecycle information. This supports effective asset management, resilience, and timely procurement of replacements. Not all teams will have a comprehensive asset list to begin with, but it is something that should be worked toward – starting with the most critical equipment, such as switchgear, water outlets, air-conditioning units, and critical ventilation etc.
5: As-fitted drawings or associated diagrams Accurate and up-to-date diagrams of installations and layouts, which are essential for maintenance, troubleshooting, and future planning. Ideally, Estates Departments would have an office exclusively reserved for Authorised Persons (APs)s to conduct permit and related administrative tasks, and particularly important drawings such as medical gas isolation points would be located here.
6: Training and competency records Documentation of training sessions, certifications, and competency evaluations for all team members, including requirements for refresher training. This should include an accurate and up-to-date list of Authorised Persons (APs) and Competent Persons (CPs) for each specialty. This is a good location to hold the register of CP, APs, AEs and DPs for each discipline, along with current appointment letters
7: Health and Safety procedures An example of this might be the Pressure Systems Safety Regulations 2000 (PSSR) guidance, to provide quick
reference for staff. Crib sheets and flow diagrams are also helpful aid memoires for operational staff.
8: Regulatory compliance records and certification A dedicated section for documenting compliance with local, national, and international regulations, including inspection reports and certification records; for example, a written scheme for lifts or pressure systems, or fixed wire testing records.
9: Performance metrics and reporting This section should detail performance records, such as critical ventilation verification. Copies of design specifications, commissioning, and verification reports, would also be useful in this section
10: Communication log A record of key internal and external communications, ensuring transparency and a clear audit trail for all decisions and actions taken. An example of this might be where an external body such as Public Health England, CQC, or HSE, has sent correspondence, information requests or interventions, or correspondence with an AE (for example, a request for guidance). The operations manuals library should be located in a central office (such as the AP’s room mentioned earlier), and there may also be other documentation at this location; for example, manufacturer’s instructions. It is always good practice to include a duty roster where front of house staff can see which AP for each discipline is on duty today, and any details of out-of-hours on-call staff where appropriate, so that they can be contacted in advance when there is out-of-hours work planned so that if there is an emergency, they are aware of what the work is, where the work is, and any additional relevant information. This will maximise efficiency in response times if, for example, a fire call is raised in a compartment adjacent to one where building work was scheduled in the evening.
Benefits of implementing Operations Manuals Holding a library of comprehensive documentation and standardised procedures ensures that Estates and Facilities teams are always prepared for audits, minimising the risk of non-compliance and associated penalties or enforcement. It instils confidence in auditors that the
The authors say one of the key elements of the Operations Manual should be an exhaustive inventory of all assets managed by the Estates & Facilities team – including equipment specifications, maintenance schedules, and lifecycle information.
Dr Scott Brown
Dr Scott Brown CEng, CSci, is the managing director and lead consultant for Health Tech Solutions, which he established in 2014. He left the NHS is 2021 after over 30 years of working in hospital engineering, and now concentrates on using his expertise in both the human and veterinary sectors, specialising in medical equipment, medical gases, and ventilation. He has specialist experience in developing and delivering tailored training courses to meet client needs. Recently the business has gained CPD-Approved status in recognition of the quality approach to its training courses. With a PhD in risk management, Scott was well placed to support large acute hospital Trusts on capital strategic replacement planning projects using a risk-based approach. He now offers his services on a consultancy basis.
January 2025 Health Estate Journal 77
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