Standards › Standard 2B › Plans and templates
Plan / template · FAC-PLN-001 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2B.9
At a glance
- List the critical services: power, water, medical gases, ventilation and clinical information systems.
- For each, set the test schedule and the back-up arrangement.
- Test each service on schedule and record the result.
- Start a failure log for every fault, with its cause and the change made.
- Review the log every quarter.
- Stop and get help straight away if: a critical service has no back-up arrangement, or a failure is not logged.
1. Purpose
To prevent failures of critical services through planned testing and back-up, and to learn from each failure so it is not repeated [EC].
2. Scope
| Applies to | Facilities, engineering, IT, and clinical leads who depend on these services |
| Locations | The whole facility |
| When | Continuously; testing on schedule; review quarterly |
| Does not apply to | Routine maintenance of individual devices, covered by EQP-SOP-001 |
3. Definitions
| Term | Meaning |
|---|---|
| Critical service | A service whose failure would put patients at immediate risk |
| Back-up | An alternative supply or system that keeps the service running until restored |
| Failure log | The record of every failure, its cause and the change made |
4. Background
Most failures in hospital services are predictable from testing and avoidable by back-up. Criterion 2B.9 requires planned prevention and analysis, not only repair after the event.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Facilities manager | Owns the plan; runs testing; keeps the failure log | Facilities engineering |
| IT lead | Owns the information system back-up and downtime plan (SOP-074) | IT competence |
| Clinical leads | Know the back-up for their area; report failures at once | Clinical management |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Testing schedule | Current; test dates per service | Visible to facilities |
| Back-up equipment (generator, UPS, gas cylinders, stored water) | Tested at the set interval | Working and in date |
| Failure log (FAC-REG-002) | Current | Updated at each failure |
7. Safety
- Do not bypass a safety device to keep a service running.
- Test back-up systems under controlled conditions only.
8. Before you start
- Check the testing schedule and the back-up status for the day.
9. Procedure
Step 1. List the critical services.
- List power, water, medical gases, ventilation and clinical information systems.
- For each, record the areas it supports and the risk if it fails.
Key point: A service left off the list is never tested.
Step 2. Set the testing and back-up.
- Set a test schedule for each service at the interval the manufacturer and the committee set (EC).
- Set the back-up arrangement, its capacity, and its test interval.
Key point: Back-up that has never been tested may not work when needed.
Step 3. Test on schedule.
- Carry out the tests and record the date, result and the tester.
- Test back-up systems under load where the plan allows.
Key point: A test is the only evidence the back-up works.
Step 4. Log every failure.
- Record each failure on FAC-REG-002: date, service, cause, duration, impact, and how it was restored.
- Find the cause, not only the symptom.
- Record the change that prevents recurrence.
Key point: A failure without a cause and a change will return.
Step 5. Review quarterly.
- Review the log and the test results each quarter.
- Look for repeated failures and ageing equipment.
- Report to the governing body.
Key point: Patterns in the log show where to invest.
10. Decision points
- If a critical service fails and back-up does not work, follow the downtime and emergency plans, and inform the chief executive at once.
11. Special situations
| Situation | Action |
|---|---|
| Planned shutdown | Inform clinical leads in advance, use the back-up plan, and record the shutdown. |
12. Escalation
- Any failure affecting patient care is reported as an incident (INC-POL-001) and to the chief executive at once.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Critical services tested on schedule | 100% | Monthly | Facilities manager | Escalate to chief executive |
| Failures logged with cause and change | 100% | Each event | Facilities manager | Review of the event |
| Back-up tested on schedule | 100% | Monthly | Facilities manager | Escalate |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Testing schedule and results | Facilities file | the period set by the facility’s records policy years |
| FAC-REG-002 Failure Log | Facilities file | the period set by the facility’s records policy years |
15. Training
- Facilities and clinical leads are briefed on the plan and their part at induction and yearly (EC).
16. Related documents
| ID | Title | Use |
|---|---|---|
| FAC-REG-002 | Failure Log | Used in step 4 |
| FAC-SOP-002 | Failure Logging and Analysis | Procedure for the log |
| SOP-074 | System Downtime Procedure (generic) | IT downtime |
| EQP-SOP-001 | Medical Equipment Maintenance | Device maintenance |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. Test intervals and back-up capacity to be set against manufacturer instructions and national rules. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | Approved by the ASF Expert Committee |
| 1.1 | the date of approval | Internal quality review: corrected cross-references, status wording and document control | Approved by the ASF Expert Committee |
E-learning for this document
- Environment & Shared Spaces (H-03)
Planned course: Planned fault prevention and maintenance. New course planned.
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)