The case for an effective Operations Manual

Maintaining compliance is an important facet in the effective management of any healthcare estate. Teams managing the estate are responsible for delivering a safe and comfortable environment, and providing spaces for clinicians and associated support services to facilitate efficient and effective patient care, while minimising revenue costs and carefully planning and implementing capital schemes. The primary goal is, and should be, safety and effectiveness. Because of this, ensuring effective dissemination of information, and robustly recording and evidencing operational activities, are important for being able to provide assurance to senior leadership and Trust management, and for demonstrating compliance for external audit.

To address these challenges, Estates teams should adopt the use of comprehensive ‘Operations Manuals’ for each discipline. This systematised approach can significantly improve consistency and transparency across estates disciplines by maintaining a library of current, relevant documents that both the in-house team and external stakeholders can access, improving communication and efficiency in both day-to-day operations, and for compliance and audit purposes. This article will outline the framework in which Estates teams might build their own library of compliance documents and regularly update and maintain them.

The Health Technical Memorandum (HTM) and Health Building Note (HBN) suites are libraries of documents published by the Department of Health, and provide overarching guidelines and principles for managing and designing healthcare facilities. The overarching document, HTM 00, was published in 2014, and outlines standards and best practices for building construction, maintenance, and operation within the healthcare sector. It covers various aspects, including infection control, sustainability, and compliance, with regulatory requirements. HTM 00 serves as a parent document for other specific HTMs, ensuring consistency and coherence in the design, use, management, and disposal, of healthcare infrastructure. This document reiterates the NHS pledge of all healthcare organisations to ‘ensure that services are provided in a clean and safe environment that is fit for purpose, based on national best practice’.1 Furthermore, Paragraph 2.4 sets out what patients should expect: ‘Patients and staff have a right to expect that engineering systems and equipment will be designed, installed, operated and maintained to standards that will enable them to function efficiently, reliably and safely.’ Therefore, the suite is published to ensure that healthcare environments are safe, efficient, and support high-quality patient care.

Discipline-specific guidance

Discipline-specific HTMs provide guidance on what type of documentation and drawings Estates teams should keep on file, but the overarching guidance in HTM 00 is more ambiguous. Paragraph 3.34 of the guidance states that ‘the organisation should have accurate and up-to-date records and/or drawings’, and that ‘where possible, these should be backed up electronically.’ However, the guidance does not provide a definitive system of record-keeping.

Later, Building Information Modelling (BIM) is highlighted as an industry standard being adopted, and now — 10 years after the HTM was published — BIM is well established, and should be a key consideration for estates management teams when assembling a library of records. It is recommended that an Estates Contingency Plan (ECP) and Facilities Contingency Plan (FCP) — documents which are a series of crib sheets used in the event of Estates and Facilities-related emergency situations, be drawn up. Some guidance is given in Appendix A of HTM 00 (2014a). Copies of these documents should be kept at the Estates and Facilities offices, at the site switchboard, and in the bronze/silver/gold command posts. These are flexible and adaptable, and can form the basis of dynamic risk assessment during situations which are fluid and developing, similar to those used by Incident Control in the Fire and Rescue Service.2

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 team takes compliance seriously, and that team members know where to look, and what to look for. Moreover, it instils confidence in the operations team, as team members always have literature to refer to when they are unsure how to proceed, and typically will have a named individual to go to when they are unable to arrive at a clear decision. Standardised procedures and clear guidelines will ultimately streamline operations, reducing variability across the disciplines (there may also be some cross-pollination in terms of both quality and specificity), and increasing efficiency. This consistency also enhances the quality of services provided.

Detailed training records and competency assessments help in identifying skill gaps in advance, which will help teams budget in a confident manner, the planning of targeted training programs, succession planning for AP and CP roles, and improve knowledge and skills in the team. This will also improve safety, in addition to the clearly defined safety procedures and emergency response protocols, which will improve consistency in emergency response, resulting in more timely and successful outcomes and a safer environment for staff and patients, reducing the overall likelihood of accidents and incidents.

A thorough asset list aids in the efficient management of resources — from maintenance to procurement, extending the lifespan of assets, reducing downtime, and allowing forward capital planning as part of a strategic replacement programme.

While the implementation of these Operations Manuals offers significant benefits, teams should be aware of the potential risks involved in implementation. Initial time and resource investment can be significant. A competent Compliance manager should be able to implement a system within 6-12 months, with the library organically growing beyond that (for example, the team may not have as-fitted drawings or asset lists, which may need to be commissioned in the next financial year). A phased approach may reduce the impact on workloads for teams.

As with all change, resistance to new ways of working can be difficult to implement. It’s really important to engage early on with all stakeholders, both at operational level and above, and highlight the benefits to them (for example, once up and running, the Operations team will significantly benefit in terms of efficiency and confidence, and the process of implementation will also help highlight shortfalls in a digestible way for senior leadership so that funding might be secured for, say, failing air plant).

Maintaining the library is key to the success of its implementation, so it’s important to establish a regular review and update process, assigning day-to-day responsibility to specific team members — such as the corresponding AP — to ensure that information remains current and accurate. The AP should be keeping these records anyway as part of their duties, so they should buy in to the process. However, this does not remove any responsibility for the corresponding committees or groups, e.g. the Medical Gas Group or Ventilation Safety Group (as set out in each specific HTM). These groups should be engaged in the process, and be a key part of reviews and acceptance. Reviews should be a standing agenda item.

Conclusions

The adoption of comprehensive Operations Manuals for each Estates and Facilities discipline can strengthen compliance management of healthcare facilities, thus improving patient safety. Standardising these documents across the disciplines in Estates & Facilities will make it easier for teams to navigate, manage, and maintain. While there are challenges to implementation, the benefits far outweigh the risks, making this a strategic investment for the Trust. We therefore make the following recommendations:

• Estates & Facilities Departments develop their own template for the Operations Manuals based on the discussions in this paper.
• Committees and Groups should be tasked with populating these manuals and identifying any gaps.
• These Committees and Groups should have a standing agenda item to review the Operations Manuals, and to have an action plan for filling any gaps.
• The asset list can inform strategic capital replacement programmes.

References

1 Health Technical Memorandum 00: Policies and principles of healthcare engineering. Department of Health (2014a), 2014. https://tinyurl.com/2u49vxbw

2 HM Government (2008, 3rd Edn.) Fire and Rescue Manual Volume 2: Fire Service Operations. The Stationery Office, Norwich. https://tinyurl.com/3b6ehefx

3 Health Building Note 00-07: Planning for a resilient healthcare estate. Department of Health (2014b), 2014. https://tinyurl.com/39ej3tt5