Standard Operating Procedure (SOP) for Hospital Maintenance

1. Purpose The purpose of this SOP is to establish a structured approach for

maintaining hospital facilities, ensuring a safe, clean, and efficient environment for
patients, staff, and visitors.

2. Scope This SOP applies to all hospital maintenance activities, including electrical,
plumbing, HVAC, biomedical equipment, and general infrastructure upkeep.

3. Responsibilities

 Maintenance Manager: Oversees all maintenance activities and ensures

compliance with regulations.
 Maintenance Staff: Perform scheduled and emergency repairs and upkeep.
 Hospital Administration: Ensures adequate resources and budgeting for
maintenance.
 Department Heads: Report maintenance issues and collaborate on solutions.

4. Preventive Maintenance

 Routine Inspections: Conduct daily, weekly, and monthly inspections of

hospital facilities.
 HVAC System: Clean and service air filters, ducts, and ventilation units
periodically.
 Electrical Systems: Inspect wiring, emergency backup systems, and generators
regularly.
 Plumbing: Check for leaks, water pressure, and proper drainage.
 Medical Equipment: Ensure biomedical devices are calibrated and serviced as
per manufacturer recommendations.
 Building Infrastructure: Inspect doors, windows, floors, and ceilings for wear
and tear.

5. Corrective Maintenance

 Emergency Repairs: Address critical failures immediately to ensure patient

safety.
 Non-Emergency Repairs: Schedule repairs based on priority levels and
impact assessment.
 Reporting System: Implement a ticketing system for maintenance requests
from departments.

6. Safety and Compliance

 Ensure maintenance staff follows hospital safety protocols.

 Use personal protective equipment (PPE) when performing repairs.
 Comply with health and safety regulations, fire codes, and infection control
guidelines.
  Maintain documentation of all maintenance activities for audit and compliance
purposes.

7. Waste Management

 Follow hospital guidelines for hazardous and biomedical waste disposal.

 Maintain proper waste segregation in maintenance activities.

8. Emergency Preparedness

 Keep emergency contact numbers for key maintenance personnel available at

all times.
 Conduct periodic drills to ensure readiness for power outages, plumbing
failures, or equipment breakdowns.

9. Training and Skill Development

 Conduct regular training sessions for maintenance staff on best practices and
new technologies.
 Provide certification and refresher courses on hospital maintenance procedures.

10. Record Keeping and Reporting

 Maintain logs of all maintenance activities, repairs, and inspections.

 Prepare periodic reports for hospital administration on maintenance efficiency
and costs.

11. Review and Continuous Improvement

 Conduct annual reviews of maintenance protocols and update SOPs as needed.

 Implement feedback from staff and audits to enhance efficiency.
Key Responsibilities of CSSD Staff:

1. Cleaning & Decontamination

 Collect used surgical instruments, trays, and medical equipment from operating
rooms and other departments.
 Remove blood, tissue, and other contaminants using approved cleaning
solutions and ultrasonic machines.
 Follow infection control protocols to prevent contamination.

2. Sterilization of Instruments & Equipment

 Operate autoclaves, steam sterilizers, ethylene oxide (ETO) sterilizers, and

other sterilization equipment.
 Follow strict sterilization cycles and parameters to ensure complete
disinfection.
 Label and track sterilized items to maintain inventory control.

3. Packing & Assembling Surgical Trays

 Arrange and package surgical trays with the required instruments for different
procedures.
 Inspect instruments for damage, defects, or malfunction before sterilization.
 Maintain proper labeling and documentation of sterilized items.

4. Inventory & Storage Management

 Maintain stock of sterile supplies, surgical instruments, and equipment.

 Ensure proper storage of sterilized items in a contamination-free environment.
 Keep records of sterilization cycles, instrument usage, and restocking needs.

5. Infection Control & Safety Compliance

 Adhere to hospital infection control policies and safety protocols.

 Dispose of biohazardous waste according to hospital and regulatory guidelines.
 Ensure compliance with hospital safety standards, including OSHA, CDC, and
WHO sterilization guidelines.

6. Equipment Maintenance & Troubleshooting

 Perform routine checks and preventive maintenance on sterilization equipment.

 Report any malfunctions or breakdowns to the biomedical engineering team.
 Keep logs of machine performance and sterilization records for audits.

7. Communication & Coordination

  Coordinate with Operating Room (OR) staff, ICU, and other departments for
timely delivery of sterilized instruments.
 Provide updates on instrument availability and restocking schedules.
 Assist in training new CSSD staff on proper sterilization techniques.

Required Skills & Qualifications:

✅ Attention to Detail – Ensuring all instruments are sterilized and accounted for.
✅ Knowledge of Sterilization Techniques – Understanding different sterilization
methods (steam, gas, chemical, plasma, dry heat).
✅ Teamwork & Communication – Working with hospital staff to meet surgical
needs.
✅ Technical Skills – Operating autoclaves, sterilizers, and other decontamination
equipment.
✅ Regulatory Compliance – Familiarity with safety regulations and infection control
guidelines.
✅ Certification (Preferred but not always required) – Certifications like Certified
Registered Central Service Technician (CRCST) or Certified Sterile Processing
and Distribution Technician (CSPDT) are beneficial.
Standard Operating Procedure (SOP) for Central Sterile Services Department
(CSSD)

The Central Sterile Services Department (CSSD) is responsible for cleaning,

sterilizing, storing, and distributing medical instruments to ensure infection control
and patient safety. This SOP outlines the step-by-step procedures to be followed in
CSSD operations.

1. Purpose

To ensure proper cleaning, decontamination, sterilization, storage, and

distribution of medical instruments and supplies, reducing the risk of infections and
maintaining hospital safety standards.

2. Scope

Applicable to all CSSD personnel, including technicians, supervisors, and assistants,

working in hospitals, clinics, and healthcare facilities.

3. Responsibilities

 CSSD Staff: Follow all sterilization and decontamination procedures.

 CSSD Supervisor: Ensure compliance with safety and sterilization standards.
 Hospital Infection Control Team: Monitor CSSD operations and conduct
audits.

4. CSSD Workflow & Procedures

Step 1: Collection of Used Instruments

✅ Collect used surgical instruments, trays, and medical devices from operating rooms
(OR), ICUs, wards, and outpatient departments.
✅ Use designated sealed containers/trolleys to prevent contamination.
✅ Segregate items according to type (sharp, delicate, heat-sensitive, etc.).

Step 2: Cleaning & Decontamination

✅ Wear personal protective equipment (PPE) – gloves, masks, aprons, eye
protection.
✅ Remove organic matter (blood, tissue, secretions) using:

 Manual Cleaning – Soft brush, enzymatic detergent.

 Ultrasonic Cleaning – Removes microscopic debris.
 Washer-Disinfector Machine – Uses water and detergent.
✅ Rinse with deionized or distilled water and inspect for residual
contamination.

Step 3: Packaging & Assembly of Instruments

✅ Dry instruments using a lint-free cloth or drying cabinet.

✅ Inspect for damage, rust, and functionality before packing.
✅ Assemble instruments into trays based on surgical procedure requirements.
✅ Wrap items using sterile wrapping material (non-woven fabric, pouches, or
rigid containers).
✅ Label each pack with:

 Sterilization date
 Expiry date
 Batch number

Step 4: Sterilization Process

Sterilize based on instrument type using one of the following methods:

Sterilization Method Process Used For

Metal instruments, trays,

Steam Sterilization (Autoclaving)
textiles

Heat-sensitive plastics,
Ethylene Oxide (ETO) Sterilization
catheters

Hydrogen Peroxide Plasma (Low-Temperature

Electronics, fiber-optic scopes
Sterilization)

Chemical Sterilization (Peracetic Acid, Endoscopes, delicate

Glutaraldehyde) instruments

Powders, oils, heat-stable

Dry Heat Sterilization
items

✅ Autoclave Cycle Parameters:

  Temperature: 121-134°C
 Pressure: 15-30 psi
 Time: 15-30 minutes

✅ Monitor sterilization effectiveness using:

 Biological indicators (spore tests)

 Chemical indicators (color-changing strips)
 Mechanical indicators (temperature & pressure logs)

Step 5: Sterile Storage & Distribution

✅ Store sterilized packs in a clean, dry, temperature-controlled environment.

✅ Follow First-In, First-Out (FIFO) system to avoid expired items.
✅ Distribute sterile supplies as per hospital department requests.
✅ Maintain records of sterilized items for traceability and audits.

5. Infection Control & Safety Measures

✅ Follow hand hygiene and wear PPE while handling sterile and non-sterile items.
✅ Dispose of biohazard waste as per hospital infection control guidelines.
✅ Ensure CSSD is cleaned daily and follows strict hygiene protocols.
✅ Conduct regular audits and equipment maintenance checks.

6. Documentation & Record-Keeping

✅ Maintain logs for:

 Instrument tracking
 Sterilization cycle reports
 Equipment maintenance records
 Staff training and competency checklists
✅ Keep records for at least 5 years for compliance audits.

7. Compliance & References

CSSD procedures must comply with:

 World Health Organization (WHO) Guidelines

 Occupational Safety and Health Administration (OSHA)
 Association for the Advancement of Medical Instrumentation (AAMI)
Standards
 Joint Commission International (JCI) Infection Control Standards
Hospital Safety Officer – Job Responsibilities

A Hospital Safety Officer ensures a safe environment for patients, staff, and visitors
by enforcing health and safety regulations, managing risk, and coordinating
emergency response procedures. Their role is crucial in preventing accidents, ensuring
compliance, and promoting a culture of safety in healthcare settings.

Key Responsibilities of a Hospital Safety Officer

1. Compliance & Regulatory Oversight

✅ Ensure hospital policies align with local health regulations.

✅ Conduct safety audits and inspections to identify hazards.
✅ Maintain documentation and records for compliance and accreditation.

2. Risk Assessment & Hazard Prevention

✅ Identify and mitigate potential safety hazards (fire, chemical, biological, radiation,
and workplace violence).
✅ Oversee infection control measures and PPE compliance.
✅ Implement risk reduction strategies to prevent hospital-acquired infections (HAIs)
and accidents.

3. Emergency Preparedness & Response

✅ Develop and update emergency response plans for fires, natural disasters, active
shooter situations, and medical emergencies.
✅ Conduct regular drills for fire safety, evacuation, and disaster response.
✅ Coordinate with emergency responders, local authorities, and hospital
administration during crises.

4. Incident Reporting & Investigation

✅ Monitor accident reports, near-miss incidents, and workplace injuries.

✅ Investigate root causes of safety incidents and develop corrective action plans.
✅ Ensure timely reporting of incidents to regulatory authorities when required.

5. Staff Training & Safety Awareness

✅ Conduct regular training programs on fire safety, hazardous material handling,

patient handling, and workplace violence prevention.
✅ Ensure proper use of personal protective equipment (PPE) among staff.
✅ Promote a safety culture through awareness campaigns and training sessions.

6. Security & Access Control

✅ Work with hospital security teams to maintain a safe environment.
✅ Ensure access control policies are enforced for restricted areas.
✅ Address incidents of theft, violence, or unauthorized entry.

7. Fire Safety & Environmental Health

✅ Ensure hospital compliance with fire codes and emergency exit regulations.
✅ Oversee proper storage and disposal of hazardous materials and biomedical waste.
✅ Monitor air quality, water safety, and other environmental health concerns.

Required Skills & Qualifications

✅ Knowledge of healthcare safety regulations (OSHA, NFPA, Joint Commission,

WHO).
✅ Risk assessment and incident investigation experience.
✅ Strong problem-solving and leadership skills.
✅ Effective communication and training abilities.
✅ Experience in emergency response and crisis management.
✅ Certifications like Certified Healthcare Safety Professional (CHSP) or Certified
Safety Professional (CSP) are beneficial.