RUMAH SAKIT AWAL BROS PEKANBARU

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2021
FIRE SAFETY PROGRAM
KEBAKARAN
KESELAMATAN
PROGRAM
 TABLE OF CONTENTS

Halaman
CHAPTER I INTRODUCTION........................................................................................ 2
CHAPTER II BACKGROUND......................................................................................... 3
CHAPTER III INTENTS................................................................................................... 4
A. Main Intent................................................................................................................ 4
B. Specific Intents.......................................................................................................... 4
CHAPTER IV PRINCIPAL AND DETAILED ACTIVITY.......................................... 5
1. Identification and Evaluation of Compliance towards Regulation, Laws, Rules,
and Other Relevant Requirement..............................................................................
......................................................................................................................5
2. Fire Safety Risk Assessment.....................................................................................
......................................................................................................................5
3. Interim Measures Implementation............................................................................
......................................................................................................................5
4. Implementation of Corrective Actions to Ensure Reduced or Absent Fire Risk.......
......................................................................................................................5
5. Provision of Early Detection System, Fire and Smoke Suppression and
Containment, and Safe Emergency Exits..................................................................
......................................................................................................................6
6. Inspection, Testing, and Maintenance of Fire Safety Mechanism and System.........
......................................................................................................................6
7. Socialization, Training, and Simulation....................................................................
......................................................................................................................6
8. Designation of Smoking Free Zone..........................................................................
......................................................................................................................7
CHAPTER V ACTIVITY IMPLEMENTATION........................................................... 8
1. Identification and Evaluation of Compliance towards Regulation, Laws, Rules,
and Other Relevant Requirement..............................................................................
......................................................................................................................8
2. Fire Safety Risk Assessment.....................................................................................
......................................................................................................................8
3. Interim Measures Implementation............................................................................
......................................................................................................................9
4. Implementation of Corrective Actions to Ensure Reduced or Absent Fire Risk.......
....................................................................................................................11

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 5. Provision of Early Detection System, Fire and Smoke Suppression and
2021
Containment, and Safe Emergency Exits..................................................................
....................................................................................................................17
RUMAH SAKIT AWAL BROS PEKANBARU
6. Inspection, Testing, and Maintenance of Fire Safety Mechanism and System.........
....................................................................................................................18
7. Socialization, Training, and Simulation....................................................................
....................................................................................................................20
8. Designation of Smoking Free Zone..........................................................................
....................................................................................................................21
CHAPTER VI TARGET.................................................................................................... 22
CHAPTER VII ACTIVITY SCHEDULE........................................................................ 23
CHAPTER VIII EVALUATION OF ACTIVITY IMPLEMENTATION AND
REPORT.............................................................................................................................. 33
A. Implementation Evaluation and Report.................................................................... 33
B. Report........................................................................................................................ 33
CHAPTER IX ACTIVITY DOCUMENTATION, REPORTING, AND
EVALUATION.................................................................................................................... 34
CHAPTER X ACTIVITY PROGRAM COST................................................................ 35
CHAPTER XI ACKNOWLEDGEMENT........................................................................ 36
CHAPTER I
INTRODUCTION

Occupational health and safety enforcement in the hospital needs very serious attention.
A hospital itself opposed some potential consequences in inevitable occupational health and
safety hazards such as radiation exposure, toxic chemicals, biological hazards, extreme
temperatures, noise, dust, and fire hazards.

A fire that had struck Kozlovichi Mental Asylum in Grodno Province, Belarus, during
October 2003 had cost the lives of 30 patients. A similar fire incident had occurred in Indonesia,
i.e., at Grogol Psychiatric Hospital, West Jakarta, in November 2008. The incident spread panic
to 30 staff and 160 psychiatric patients had to be evacuated.

Hospital is a place that is closely related to every potential hazardous incident or fire; thus, a
system should be designed to properly manage fire hazards, identify and provision the proper
emergency response equipment, and periodically test the equipment

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 CHAPTER II
BACKGROUND

1. Ministry of Public Works Ministerial Regulation No. 26/PRT/M/2008 about Technical

Requirements of Fire Protection System in Buildings and Environment (Peraturan
Menteri Pekerjaan Umum Nomor 26/PRT/M/2008 tentang Persyaratan Teknis Sistem
Proteksi Kebakaran pada Bangunan Gedung dan Lingkungan)
2. Ministry of Manpower Ministerial Decision No. 186/MEN/1999 about Fire Safety Unit in
the Workplace (Keputusan Menteri Tenaga Kerja Republik Indonesia Nomor
186/MEN/1999 tentang Unit Penanggulangan Kebakaran di Tempat Kerja)
3. Ministry of Manpower Ministerial Regulation No. 04/MEN/1980 about Fire Extinguisher
Maintenance and Installment Requirements (Peraturan Menteri Tenaga Kerja Republik
Indonesia Nomor 04/MEN/1980 tentang Syarat – Syarat Pemeliharaan dan Pemasangan
APAR)
4. Ministry of Health Ministerial Regulation No. 4 Year 2016 about Medical Gas and
Vacuum Use in Healthcare Facility (Peraturan Menteri Kesehatan Republik Indonesia

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 Nomor 4 Tahun 2016 tentang Penggunaan Gas Medik dan Vakum Medik pada Fasilitas
Pelayanan Kesehatan)
5. Ministry of Health Ministerial Regulation No. 24 Year 2016 about Technical
Requirements for Hospital Building and Facility (Peraturan Menteri Kesehatan Republik
Indonesia Nomor 24 Tahun 2016 tentang Persyaratan Teknis Bangunan dan Prasarana
Rumah Sakit)

CHAPTER III
INTENTS

1. Main Intent
The fire safety program is designed and implemented to protect all hospital
facility occupants from fire and smoke. The fire safety program also handles non-fire
emergencies; including, a toxic gas leak that may oppose hazard towards hospital
occupants needing evacuation.

2. Specific Intents
Conduct risk identification analysis and prepare the necessary steps to minimize fire risk,
including:

1. Fire separations
2. Smoke separations/compartments
3. Hazardous areas (and spaces above the ceilings in those areas) such as soiled linen
rooms, trash collection rooms, and oxygen storage rooms
4. Fire emergency exits

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5. Kitchen grease-producing cooking devices
6. Laundry and trash chutes
7. Emergency power systems and equipment
8. Medical gas and vacuum system components
9. Storage and handling of potentially flammable materials (for example, flammable
liquids, combustible gases, and oxidizing medical gases such as oxygen and nitrous
oxide).
10. Procedures and precautions to prevent and manage surgical fires.
11. Fire hazards related to construction, renovation, or demolition projects.

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 CHAPTER IV
PRINCIPAL AND DETAILED ACTIVITY

1. Identification and Evaluation of Compliance towards Regulation, Laws, Rules, and

Other Relevant Requirement
2. Fire Safety Risk Assessment
1. Fire Safety Risk Identification
1) Fire separations
2) Smoke separations/compartments
3) Hazardous areas (and spaces above the ceilings in those areas) such as soiled
linen rooms, trash collection rooms, and oxygen storage rooms
4) Fire emergency exits
5) Kitchen grease-producing cooking devices
6) Laundry and trash chutes
7) Emergency power systems and equipment
8) Medical gas and vacuum system components
9) Storage and handling of potentially flammable materials (for example,
flammable liquids, combustible gases, and oxidizing medical gases such as
oxygen and nitrous oxide).
10) Procedure and precautions to prevent and manage surgical fires
11) Fire hazards related to construction, renovation, or demolition projects
2. Risk Analysis
3. Risk Prioritization
4. Risk Mitigation
3. Interim Measures Implementation
4. Implementation of Corrective Actions to Ensure Reduced or Absent Fire Risk
1. Assigning Fire Marshal Team
1) Fire Marshal Team of Awal Bros Hospital Pekanbaru.
i. Fire Command Center
ii. Fire Marshal Team in Units
iii. Communication Team
iv. Security Team
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 v. Maintenance Team
vi. Medical Team
vii. Evacuation Team
2. Determining Fire Safety Mechanism
3. Inspection of Water Access and Supply to Extinguish Fire
4. Fire Ignition Source Control
5. High-Temperature Equipment Use Control
6. Electrical Hazard Control
7. Welding and Cutting Work Control
8. Storage and Handling Management of Potentially Flammable Materials
9. Fire Safety in Medical Records Unit

5. Provision of Early Detection System, Fire and Smoke Suppression and

Containment, and Safe Emergency Exits
a. Early warning and detection systems and notification systems, such as smoke
detectors, fire alarm and fire patrols
b. Fire extinguishing mechanisms, such as water hoses, fire extinguishers, chemical
suppressants, or sprinklers
c. Fire and smoke containment, including fire separation and smoke compartment
d. Safe and unobstructed exit access in cases of fire or non-fire emergencies

6. Inspection, Testing, and Maintenance of Fire Safety Mechanism and System

a. Early warning and early detection systems, and notification systems, such as
smoke detectors, fire alarms and fire patrols
b. Fire suppression mechanisms, such as water hoses, fire extinguishers, chemical
suppressants, or automatic sprinklers
c. Fire and smoke containment, including fire separation and smoke compartments
d. Safe and unobstructed access to exit in the event of a fire or non-fire emergency

7. Socialization, Training, and Simulation

a. Socialization and Education
b. Training

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 i. New recruits
ii. Vendors
iii. Tenants
iv. Outsourcing
v. Employees who need re-certification
c. Simulation
i. Fire drill
ii. Fire safety simulation and evacuation

8. Designation of Smoking Free Zone

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 CHAPTER V
ACTIVITY IMPLEMENTATION

1. Identification and Evaluation of Compliance towards Regulation, Laws, Rules, and

Other Relevant Requirement
Occupational Health and Safety Committee identifies regulations, constitutions,
reports, and other requirements regarding fire safety at least annually or after every
change. Compliance with regulations, constitutions, laws and other applicable
requirements are evaluated annually and followed-up for every discrepancy. Compliance
with regulation, constitution, and other national regulations about fire safety is
continuously assessed to identify and minimize risk.

2. Fire Safety Risk Assessment

1. Fire Safety Risk Identification
Risk identification and hazard analysis regarding fire safety are conducted
by Occupational Health and Safety Committee, Quality and Patient Safety
Committee, Coordinators, and Managers with Director approval. Risk
identification is undertaken at least annually or at least after every service or
pathway process changes in the hospital or after any other changes using the
Facility Safety Risk Identification Form , which includes:

a. Fire separation
b. Hazardous areas (and spaces above the ceilings in those areas) such as
soiled linen rooms, trash collection rooms, and oxygen storage rooms
c. Fire emergency exits
d. Kitchen grease-producing cooking devices
e. Laundry and trash chutes
f. Emergency power systems and equipment
g. Medical gas and vacuum system components

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 h. Storage and handling of potentially flammable materials (for example,
flammable liquids, combustible gases, and oxidizing medical gases such
as oxygen and nitrous oxide)
i. Procedure and precautions to prevent and manage surgical fires
j. Fire hazards related to construction, renovation, or demolition projects

2. Risk Analysis
Risk identification which includes all the above points is analyzed based on its
frequency and impact on hospital operational and safety. The risk level is determined,
and necessary actions are taken to mitigate the risk. Risks may include risk towards
equipment, systems, or other fire safety features which are damaged, obstructed,
malfunctioned, or has to be moved. Risks could also be identified from construction
projects, hazardous storage conditions, equipment, system damage, or compulsory
maintenance, opposing fire safety risks.

3. Risk Prioritization
The identified fire safety risks are then prioritized based on risk level. Thus the
working unit/area could be mapped based on the fire risk stratification. The mapping
may be changed should there be identified risk changes, activity process changes, or
area function changes or during the review annually.

4. Risk Mitigation
The identified risk is handled and corrected (through corrective measures, moving,
changing, etc.). If the risks are unable to be addressed immediately, the hospital
implements interim measures.

3. Interim Measures Implementation

An interim measure is implemented actions to ensure staff and patient safety during
fire safety system damage, obstruction, or when the system is inoperable due to
construction, maintenance, disturbance, or repair. The hospital considers the risk as
opposed to the patients, staff, or others during planning and time-framing to implement
corrective and/or interim measures at the moment of fire safety damage or disturbance.

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Risk consideration is conducted sustainably and is reviewed at least annually. Interim
measures are implemented at Awal Bros Hospital Pekanbaru during these conditions:

a. The fire alarm system malfunctioned for more than 2 hours in 1 day.
b. Sprinkler system stopped operating for more than 7 hours in 1 day.
c. Standard exit path or door is inaccessible or not functioning due to maintenance
or construction.
d. Primary hydrant pump function failure or damage.
e. Insufficient water supply to extinguish the fire.

Interim measures for the above conditions include,

a. Fire monitoring by a trained individual patrolling affected areas on the building to

look for evidence of smoke, fire, or other abnormal conditions.
b. Signs placement to identify alternative exits for every affected individual in the
hospital (i.e., when the standard exit paths dan/or door is inaccessible or
malfunctioned due to construction, maintenance, etc.).
c. Exit door inspection on the affected area every day
d. Provision of additional fire extinguishers.
e. Use of temporary construction partitions made with smokeproof material or
fireproof materials which prevents fire from spreading.
f. Increase building, land, and equipment supervision and pay special attention to
construction and storage areas.
g. Implements storage system, household maintenance, and debris disposal to reduce
the spread of fire to the very least.
h. Provision of additional training for staff about fire extinguishing equipment.
i. Additional fire safety training for staff.
j. Inspection and testing of interim fire safety measures every month.
k. Education to increase awareness about building shortcomings, including fire,
damage, construction hazard, and interim measures to maintain fire safety.
l. Provision of additional training for staff to compensate for increased risk due to
structural or safety feature component damage.
m. Other interim measures are taken based on the identified fire safety risks.

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4. Implementation of Corrective Actions to Ensure Reduced or Absent Fire Risk
1. Assigning Fire Marshal Team
1) Fire Marshal Team with the Occupational Health and Safety for Fire Proficiency
Certification from Department of Manpower.
Fire Marshal Team with the Occupational Health and Safety for Fire Proficiency
Certification from Department of Manpower. Based on Ministry of Manpower
Ministerial Regulation No. 186/MEN/1999 about Fire Fighting Unit in the
Occupational (Keputusan Menteri Tenaga Kerja Republik Indonesia No
186/MEN/1999 tentang Unit Penanggulangan Kebakaran di Tempat Kerja),
Awal Bros Hospital Pekanbaru must own a fire marshal team with Occupational
Health and Safety for Fire Proficiency (Ahli K3 Kebakaran) Certification issued
by Department of Manpower as many as:

i. Level D = Fire Safety Officer Leader: 24 people

ii. Level C = Fire Fighting Team: 6 people
iii. Level B = Fire Fighting Unit Coordinator: 3 people
iv. Level A = Occupational Health and Fire Safety Specialist/Expert: 1 person

This team is on duty during a fire emergency and in charge of minimizing and
identifying fire risk. The duty of each team is as follows,

i. Level D = Fire Safety Officer Leader: 24 people

● The duty of Fire Safety Officer includes
○ Identify and report factors that may oppose fire hazard
○ Extinguish fire in early stages
○ Direct person and goods evacuation
○ Coordinate with related institutions
○ Secure fire location.
● Fire Safety Officer requirements:
○ Physically and mentally healthy
○ Minimum middle school graduate

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 ○ Have attended level basic I technical fire-fighting
course/training.

ii. Level C = Fire Fighting Team: 6 people

● The duty of the Fire Fighting Team includes
○ Identify and report factors that may oppose fire hazard
○ Fire protection facility maintenance
○ Provide education about fire management in the early stages
○ Helps in writing fire safety plan guide book
○ Extinguish fire
○ Direct person and good evacuation
○ Coordinate with related institutions
○ Provide first aid on fire
○ Secure workplace location
○ Coordinate with all fire safety officer
● Fire Fighting Team requirements:
○ Physically and mentally healthy
○ Aged 25 years old minimum and 45 years old maximum
○ Minimum middle school graduate
○ Have attended level basic II technical fire-fighting
course/training
iii. Level B = Fire Fighting Unit Coordinator: 3 people
● The duty of the Fire Fighting Unit Coordinator includes:
○ Leads fire-fighting activity before the help of authorized agency
arrives
○ Arrange working program and activity about fire fighting
○ Propose a budget for fire-fighting facilities and infrastructure to
the board of management.
● Fire Fighting Unit Coordinator requirements:
○ Physically and mentally healthy
○ Minimum middle school graduate

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 ○ Working experience of a minimum of five years in the associated
institution
○ Have attended technical fire-fighting course/training

iv. Level A = Occupational Health and Fire Safety Specialist/Expert: 1 person

● The duty of Occupational Health and Fire Safety Expert includes:
○ Helps in supervising the fire-fighting regulation implementation
○ Reports to the minister or appointed official based on the applicable
regulations
○ Conceal every associated confidential information about the
company or institution
○ Leads fire-fighting activity before the help of authorized agency
arrives
○ Arrange working program and activity about fire fighting
○ Coordinate with related institutions
● Occupational Health and Fire Safety Expert requirements:
○ Physically and mentally healthy
○ Minimum diploma 3 in engineering graduate
○ Working experience of minimum five years in the associated
institution
○ Have attended technical fire-fighting course/training level basic I,
essential II, and the Occupational Health and Safety Expert Primary
and Intermediate level
● On duty, the Occupational Health and Fire Safety Expert also have
five of the authority to:
○ Instruct, stop and reject working activities that may oppose fire or
explosion risk
○ Ask for information regarding fire safety requirements
implementation in the workplace.

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 Based on these requirements, Awal Bros Pekanbaru Hospital planned the
formation of the Fire Fighting Team Level A, B, and certificate renewal for
Level C and D. Level A training certification is scheduled for 2021. Level B
training certification for four people is arranged in the mid-year of 2021 or based
on the local training facility quota. Fire safety certification renewal for 24 people
in levels C and D is planned for the first trimester of 2021.

2) Fire Fighting Team Awal Bros Hospital Pekanbaru

The fire-fighting team in Awal BrosPekanbaru Hospital is written on an
on-duty emergency schedule. The fire-fighting team on each unit is placed based
on risk stratification and working area. The on-duty schedule is renewed every
shift by the unit/area in-charge coordinator. The on-duty staff must understand
their roles and responsibilities.

Fire-Fighting Team consists of:

i. Fire Command Center

ii. Fire Fighting Team in Units
iii. Communication Team
iv. Security Team
v. Maintenance Team
vi. Medical Team
vii. Evacuation Team

2. Determining Fire Safety Mechanism. A fire-fighting mechanism is determined by:

1. Establishment of fire-fighting procedure by Occupational Health and Safety
Committee. The procedure is reviewed at least every three years.
2. Inventory of facility and infrastructure for firefighting by Occupational Health
and Safety Committee at least annually
3. Fire simulation and evaluation to test if the applied procedure is still relevant or
in need of change/revision by the Occupational Health and Safety Committee.
The simulation is conducted at least annually.

3. Inspection of Water Access and Supply to Extinguish Fire

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 To minimize fire impact in cases of fire, Awal Bros Hospital Pekanbaru has provided
a water supply for the hydrant.

1. Water supply for fire extinguishing in Awal Bros Pekanbaru Hospital is

available 24 hours under the supervision of the Maintenance unit.
2. Ensuring firefighter trucks have unobstructed access to all paths in the hospital.
3. Restrict vehicle traffic in cases of fire.
4. Provision of Siamese connection in designated areas to ensure water supply.
5. Siamese connections are tested and inspected by Fire Department Pekanbaru at
least annually.

4. Fire Ignition Source Control

1) Nutrition Unit. The nutrition unit is one of some places for a fire ignition source,
especially in the food processing room (kitchen). Fire safety in the kitchen
includes,
i. Provision and maintenance of fire extinguisher by Occupational Health and
Safety Committee
ii. Installment and maintenance of automatic fire extinguisher in cooking area
kitchen hood using wet chemical fire suppression system. Maintenance by
a third party is conducted at least annually.
iii. Education and training for all Nutrition Unit staff about the use of fire
extinguishers and fire safety procedures by Occupational Health and Safety
Committee in coordination with Education and Training Unit.

2) Food court(outside building area)

i. Provision and maintenance of fire extinguishers by the Occupational Health
and Safety Committee.
ii. Education and training for tenants in the food court area about the use of
fire extinguishers and fire safety procedures by the Occupational Health
and Safety Committee in coordination with the Education and Training
Unit.

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5. High-Temperature Equipment Use Control
1) Autoclave Use
i. Periodical maintenance is conducted monthly by Medical Maintenance
Officer.
ii. The autoclave is calibrated annually by a competent third party.
iii. The autoclave is operated by a trained CSSD and laboratory officer.

6. Electrical Hazard Control

1. System grounding. The grounding system which is used is tested annually
by the Department of Manpower Pekanbaru.
2. Electrical panels are checked every shift by the Maintenance Unit.
3. Electrical panels maintenance is conducted monthly by the Maintenance
Unit.

7. Welding and Cutting Work Control

1. Welding or cutting work may be done by an internal party (Maintenance
Unit) or by the appointed external vendor.
2. These works are supervised by the Occupational Health and Safety
Committee.

8. Storage and Handling Management of Potentially Flammable Materials

Safe storage and handling of flammable materials, including medical gas, is
managed in the following ways:

1) Medical gas management

 Provision of medical gas is carried out by Medical Logistics per request
from the Maintenance Unit.
 Medical gas is received by Medical Logistics and Maintenance Unit
 The Maintenance Unit stores medical gas under the supervision of
Medical Logistics.
 The central system for medical gas maintenance is conducted by an
external party every three months.

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  The medical gas central panel is inspected by the Maintenance Unit every
shift.
i. Medical gas central service is conducted by an external party every
planned maintenance or after every maintenance.
2) The hazardous and toxic materials storage control. Hazardous and toxic materials
storage is controlled monthly by the Occupational Health and Safety Committee.
3) Management of non-fire emergencies which might oppose safety hazards and
evacuation needs. Non-fire emergencies include,
i. Toxic gas leak.
ii. Earthquakes (infrastructure collapse risk).
iii. Other non-fire emergencies in need of evacuation as listed in the
procedure.
9. Fire Safety in Medical Records Unit
To protect medical record files from fire, Awal Bros Hospital Pekanbaru has
provided:

1. Thermatic fire extinguisher: a powder-type fire extinguisher attached to the

ceiling based on the room requirement; thus, during the fire, the extinguisher
is automatically on to extinguish the fire, which will not damage the medical
record file. There areeight units of thermatic fire extinguishers available in
the medical record unit.
2. CO2 fire extinguisher: This is a manually operated fire extinguisher whose
active ingredients will not damage medical record files in contact. There are
two units of CO2 fire extinguishers available in the medical record unit.
3. All fire extinguishers (either thermatic or CO2 fire extinguisher) are inspected
for their appropriateness monthly by the Occupational Health and Safety
Committee and are documented in fire extinguisher checklist.

5. Provision of Early Detection System, Fire and Smoke Suppression and

Containment, and Safe Emergency Exits
Occupational Health and Safety Committee planned a fire safety system which includes,

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 a. Early warning and detection system and notification systems, such as smoke
detectors, fire alarm, and fire patrols.
b. Fire extinguishing mechanisms, such as water hoses, fire extinguishers, chemical
suppressants, or sprinklers.
The logistics Unit provides fire extinguishers and their parts based on the request
from Occupational Health and Safety Committee as needed.

c. Fire and smoke containment, including fire separation and smoke compartment.
d. Safe and unobstructed exit access in cases of fire or non-fire emergencies
Clear and unobstructed evacuation route and emergency stairs are ensured through,

i. Equip lightings for corridors and emergency stairs. Lighting using an emergency
lamp with battery power is inspected by security every 3 hours, and broken
lighting is reported to the Maintenance Unit.
ii. Installation of exit signs which are clear and understandable for all staff, patients,
and hospital visitors.
iii. Installation of signs or education regarding necessary caution to prevent fire is
clear and easily understandable for all staff, patients, and hospital visitors.

6. Inspection, Testing, and Maintenance of Fire Safety Mechanism and System

Inspection, Testing, and Maintenance of Fire Safety Mechanism and System is conducted
by Occupational Health and Safety Committee, which includes,

a. Early warning and detection systems and notification systems, such as smoke
detectors, fire alarm and fire patrols
i. Inspection of early warning and detection systems, such as smoke detectors, fire
alarms, is conducted by the maintenance unit monthly
ii. Maintenance and repair are conducted by an external agency every year as
required by the applicable local regulations, laws, and rules, either of which has a
stricter requirement.
iii. Inspection and certification of permits are issued by the Fire Department annually.
iv. Fire patrol is conducted every 3 hours by a Security Officer.

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b. Fire extinguishing mechanisms, such as water hoses, fire extinguishers, chemical
suppressants, or sprinklers
i. Inspection of fire extinguishers, such as water hoses, fire extinguishers,
chemical suppressants, is conducted by the Occupational Health and
Safety Committee every month.
ii. The Occupational Health and Safety Committee conducts internal
maintenance every month, while an external agency undertakes external
maintenance and repair.
iii. Inspection and certification permit is issued by Fire Department annually

c. Fire and smoke containment, including fire separation and smoke compartment.
The effectiveness of fire and smoke containment is evaluated through the following
actions:

i. Compartment door function test by Occupational Health and Safety

Committee every month by activating the alarm.
ii. Fire and smoke containment function test is conducted by Occupational
Health and Safety Committee at least annually using artificial smoke.

d. Safe and unobstructed exit access in cases of fire or non-fire emergencies

Safe (clear and unobstructed) evacuation routes and emergency stairs are managed
through these actions:

i. The evacuation route is cleaned by the Cleaning Service every week.

ii. The evacuation route is checked by security every Amano patrol or every 3
hours.
iii. The evacuation route is inspected by the Occupational Health and Safety
Committee every month.
iv. Damage or repair needed for the evacuation route and emergency stairs is
conducted by the Maintenance Unit based on a security check report and
inspection by Occupational Health and Safety Committee.
v. Lighting is checked by security every 3 hours, and should there be any
damage, the security reports the damage to the Maintenance Unit.

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 vi. The corridor that connects the room with exits must be unobstructed,
checked by security every 3 hours.
vii. Installation of exit signs must be clear and understandable for all staff,
patients, and hospital visitors.
viii. Installation of signs or education regarding necessary caution to prevent
fire is clear and easily understandable for all staff, patients, and hospital
visitors.

7. Socialization, Training, and Simulation

a. Socialization and Education
Socialization and education are provided for all employees, patients,
patients’families, visitors, tenants, outsourcing, interns, and others outside training
schedules, for example, during inspection to working units.

b. Training
Fire safety training is organized as a part of Facility Management and Safety training.
The training is routinely conducted monthly by Occupational Health and Safety
Committee in coordination with the Education and Training Unit and is attended by:

i. New recruits
ii. Vendors
iii. Tenants
iv. Outsourcing
v. Employees who need re-certification
Staff who have attended fire safety program training are evaluated regarding their
knowledge and must elaborate on how to evacuate patients to the designated secure
area in case of emergency. Fire safety program training results are documented,
evaluated and determine which staff requires remedial tests or re-training about fire
safety program training.

c. Simulation. Fire simulation is divided into:

i. Fire drill

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 The fire drill is conducted to evaluate all staff (including outsourcing) regarding
their knowledge of fire management procedures. The fire drill is conducted
every month with a target of 100% employees who have participated in a fire
drill at least once a year.

ii. Fire simulation/ evacuation simulation

Fire simulation/evacuation simulation is conducted at least annually, which
involves an appointed employee as CODE RED officer during simulation. This
simulation aims to evaluate employee knowledge about evacuation procedures
during cases of fire and, at the same time, test fire emergency response
equipment. Fire drills and simulation do not involve patients and their families.

8. Designation of Smoking Free Zone

Awal Bros Hospital Pekanbaru prohibits all smoking activity inside and around the
hospital area (including renovation and construction areas). The smoking prohibition
applies to all staff, vendors, outsourcing, patients, families, and visitors. The smoking
prohibition includes but is not limited to cigarettes, pipes, electronic cigarettes, and other
ignition sources for smoking.

A Smoke-free zone is implemented through these steps:

● Monitor implementation of the smoke-free zone by security every Amano patrol

schedule
● Involve employees to report smoking incidents around Awal Bros Hospital
Pekanbaru actively
● Reprimand the employees who violate the prohibition, based on the reports from
each manager to the Human Resource Department with attached evidence of prior
coaching to issue a procedural written warning.
● Smoking prohibition around renovation and construction areas

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 CHAPTER VI
TARGET

1. Zero accidents, i.e., no fire incident in Awal Bros Hospital and no workplace accident
due to fire incident in the hospital.
2. 100% of all staffcan understand the fire safety system in the hospital
3. 100% of all equipment are well-maintained
4. 100% of all evacuation routes are unobstructed
5. 100% of all staff and vendors received fire training and simulation every year
6. 100% of all staff and visitors are not smoking around the hospital

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 CHAPTER VII
ACTIVITY SCHEDULE

MONTH FREQ LOCATION PIC

ACTIVITY
NO ACTIVITY
SUBJECT
1 2 3 4 5 6 7 8 9 10 11 12

1 Program Planning Meeting Notes                       √ Annually Morning Report Occupational Health

Meeting Room & Safety Committee

2 Routine Program Coordination Meeting about fire safety program √ √ √ √ √ √ √ √ √ √ √ √ Monthly Morning Report Human Resource
Meeting execution Room Department &
Occupational Health
& Safety Committee

3 Program 1 Identification and Evaluation of Compliance                              

towards Regulation, Laws, Rules and Other
  Relevant Requirement

  2 Fire Safety Risk Assessment                        

 
a. Risk Identification √                       Occupational Health
& Safety
  Annually Meeting Room Committee,
b. Risk Analysis √                      
Coordinators,
  c. Risk Prioritization √                      
Unit/Ward

  d. Risk Mitigation √                      

  3 Interim Measures Implementation                         As needed All identified Occupational Health

areas & Safety Committee

  4 Implementation of Corrective Actions to Ensure                              

Reduced or Absent Fire Risk
 

  a. Assigning Fire Marshal Team                              

  i Fire Department Certification                         Every 3 years External Occupational Health

& Safety Committee
  & Education &
Training Unit

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NO ACTIVITY ACTIVITY MONTH FREQ LOCATION PIC
SUBJECT
  ii Emergency PIC Supervision √ √ √ √ √ √ √ √ √ √ √ √ Every Shift Awal Bros Batam Coordinators, Unit
Hospital & Ward Leader
 
b. Determining Fire Safety Mechanism                              
 
i Implement SOP √                       Every 3 years Awal Bros Batam Occupational Health
  Hospital & Safety
ii Inventory of facility and √                       Annually Committee, Quality
  infrastructure for firefighting and Patient Safety
Committee

  iii Simulation                       √ Annually

      c. c. Inspection of Water Access and Supply to                              

Extinguish Fire
 
i Water supply provision √ √ √ √ √ √ √ √ √ √ √ √ 24 hours Awal Bros Batam Occupational Health
  Hospital & Safety Committee
ii Provision of firefighting truck access √ √ √ √ √ √ √ √ √ √ √ √ 24 hours
 
iii Restriction of vehicle traffic in cases                         As needed
  of fire

  iv Provision and maintenance of √ √ √ √ √ √ √ √ √ √ √ √ Monthly Maintenance Unit

Siamese connection
 
v Function test and inspection of             √           Annually Occupational Health
Siamese connection & Safety Committee
  & External

  d. Fire Ignition Source Control                              

  Nutrition Unit                              

    Provision and maintenance of fire √ √ √ √ √ √ √ √ √ √ √ √ Monthly Nutrition Room Occupational Health

extinguisher (portable & central) & Safety Committee
 
  Installation and maintenance of fire     √                   Annually Occupational Health
extinguisher & Safety Committee
  & External

    Education √ √ √ √ √ √ √ √ √ √ √ √ Monthly Education & Occupational Health

& Safety Committee

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 MONTH FREQ LOCATION PIC
ACTIVITY
NO ACTIVITY
  SUBJECT Training Room & Education &
Training Unit
 
Food Court                              
    Provision and maintenance of fire   √                     Annually Food court Occupational Health
extinguisher & Safety Committee
 
  Education √ √ √ √ √ √ √ √ √ √ √ √ Monthly Education & Occupational Health
  Training Room & Safety Committee
& Education &
Training Unit
 
e High Temperature Equipment Use Control                              
 
Autoclave                              
 
  Maintenance √ √ √ √ √ √ √ √ √ √ √ √ Monthly CSSD & Medical
  Laboratory Maintenance

  Calibration   √                     Annually Medical

  Maintenance &
External
 
  Operation √ √ √ √ √ √ √ √ √ √ √ √ Daily CSSD & Laboratory
 
  Ministry of Environment and               √         Every 5 years External
Forestry Permit
 
f. f. Electrical Hazard Control                              
 
i System Grounding                       √ Annually Grounding Occupational Health
  & Safety
ii Electrical Panel Inspection √ √ √ √ √ √ √ √ √ √ √ √ Every Shift Electrical Panel Committee,
  Room Maintenance Unit &
iii Electrical Panel Maintenance √ √ √ √ √ √ √ √ √ √ √ √ Monthly External Agency
 
g. Welding and Cutting Work Control                              
 

  i Welding and Cutting Work                         As needed Workshop or Maintenance Unit &

project location External
 
ii Supervision                         Based on each Occupational Health

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NO ACTIVITY ACTIVITY MONTH FREQ LOCATION PIC
SUBJECT
  duties & Safety Committee

  h. Storage and Handling Management of                            

Potentially Flammable Materials
 
i Medical Gas Control                            
 
Procurement √ √ √ √ √ √ √ √ √ √ √ √ As needed Awal Bros Batam Logistics &
  Hospital Maintenance Unit

  Reception √ √ √ √ √ √ √ √ √ √ √ √ As needed Liquid Tank

  Storage √ √ √ √ √ √ √ √ √ √ √ √ Daily Medical Gas

Central Room
 
        Medical gas panel system     √     √     √     √ Every 3 Medical Gas Maintenance Unit &
maintenance months Central Room & External
  Liquid Tank
Medical gas panel system inspection √ √ √ √ √ √ √ √ √ √ √ √ Every shift Maintenance Unit
 

  Medical gas panel system service √ √ √ √ √ √ √ √ √ √ √ √ Monthly or Maintenance Unit &

after every External
  procurement

  ii Hazardous and toxic materials √ √ √ √ √ √ √ √ √ √ √ √ Monthly All hospital areas Occupational Health
storage control & Safety Committee
  iii Management of non-fire emergency                         As needed All hospital areas Occupational Health
which might oppose safety hazard & Safety Committee
  and evacuation need.

  i. Fire Safety in Medical Records Unit                              

 
  Fire Extinguisher Refill   √     √               Annually Medical Records Occupational Health
& Safety Committee
 
  Fire Extinguisher Inspection √ √ √ √ √ √ √ √ √ √ √ √ Monthly

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NO ACTIVITY ACTIVITY MONTH FREQ LOCATION PIC
SUBJECT
5 Provision of Early Detection System, Fire and                              
Smoke Suppression and Containment, and Safe
Emergency Exits

a. Early warning and detection system, and                         As needed   Logistics Unit,

notification system, such as smoke General Affairs,
detectors, fire alarm and fire patrols. Occupational Health
& Safety Committee

      Fire Patrol √ √ √ √ √ √ √ √ √ √ √ √ Every 3 hours   Security

b. Provision of fire extinguishing mechanism,                         As needed Logistics Unit,

such as water hose, fire extinguisher, General Affairs,
chemical suppressants or sprinklers Occupational Health
& Safety Committee

    c. Provision of fire and smoke containment,                         As needed   Logistics Unit,

including fire separation and smoke General Affairs,
compartment. Occupational Health
& Safety Committee

d. Safe and unobstructed exit access in cases                              

of fire or non-fire emergencies

Equip lightings for corridors and emergency                              

stairs

  Provision √ √ √ √ √ √ √ √ √ √ √ √ 24 hours Awal Bros Batam Maintenance Unit

Hospital
  Testing √ √ √ √ √ √ √ √ √ √ √ √ Every 3 hours Security

  Inspection √ √ √ √ √ √ √ √ √ √ √ √ Monthly Occupational Health

& Safety Committee

Installation of Exit Signs                         As needed Occupational Health

& Safety Committee

Installation of Signs and Education                         As needed Occupational Health

& Safety Committee

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NO ACTIVITY ACTIVITY MONTH FREQ LOCATION PIC
SUBJECT
  6 6. Inspection, Testing and Maintenance of Fire                              
Safety Equipment and System

    a.                              

Early warning and detection system, and

notification system, such as smoke detector,
fire alarm and fire patrols

    Fire and Smoke Detector                              

    i System check √ √ √ √ √ √ √ √ √ √ √ √ Monthly   Maintenance Unit

    ii External maintenance and repair             √           Annually Awal Bros Batam Maintenance Unit &
Hospital External

    iii Inspection and certification of             √           Annually Maintenance Unit &

permits External

      Fire Alarm                              

      i System check √ √ √ √ √ √ √ √ √ √ √ √ Monthly   Maintenance Unit

      ii External maintenance and repair             √           Annually Awal Bros Batam Maintenance Unit &
Hospital External

      iii Inspection and certification of             √           Annually Maintenance Unit &

permits External

      Fire Patrol √ √ √ √ √ √ √ √ √ √ √ √ Every 3 hours   Security

    b. Fire extinguishing mechanism, such as                           Awal Bros Batam  

water hose, fire extinguisher, chemical Hospital
suppressants or sprinklers

    Fire Hose, Hydrant System, Hydrant Pump                              

      System check √ √ √ √ √ √ √ √ √ √ √ √ Monthly   Maintenance Unit

      External maintenance and repair             √           Annually Awal Bros Batam Maintenance Unit &
Hospital External

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NO ACTIVITY ACTIVITY MONTH FREQ LOCATION PIC
SUBJECT
        Inspection and certification of             √           Annually Maintenance Unit &
permits External
 
    Fire Extinguisher                              
 
  Checking √ √ √ √ √ √ √ √ √ √ √ √ Monthly   Occupational Health
  & Safety Committee

    Maintenance and repair             √           Annually Awal Bros Batam Occupational Health

Hospital & Safety Committee
  & External

    Inspection and certification of             √           Annually Occupational Health

permits & Safety Committee
  & External

  Sprinkler                              

    System check √ √ √ √ √ √ √ √ √ √ √ √ Monthly   Maintenance Unit

    External maintenance and repair             √           Annually Awal Bros Batam Maintenance Unit &
Hospital External
 
  Inspection and certification of             √           Annually Maintenance Unit &
  permits External

      c.                              
Fire and smoke containment, including fire
  separation and smoke compartment.

      Compartment door                              
 
    Checking √ √ √ √ √ √ √ √ √ √ √ √ Monthly   Occupational Health
  & Safety Committee

      Maintenance and repair             √           Annually Awal Bros Batam Occupational Health

Hospital & Safety Committee
& External
 
    Inspection and certification of             √           Annually Occupational Health
  permits & Safety Committee
& External
 
      Beam Detector                              

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NO ACTIVITY ACTIVITY MONTH FREQ LOCATION PIC
SUBJECT
      Checking √ √ √ √ √ √ √ √ √ √ √ √ Monthly   Occupational Health
& Safety Committee
 
    Maintenance and repair             √           Annually Awal Bros Batam Occupational Health
  Hospital & Safety Committee
& External
 
    Inspection and certification of             √           Annually Occupational Health
permits & Safety Committee
 
& External
 
    d. Safe and unobstructed exit access in cases                              
of fire or non-fire emergencies
 

 
      i Evacuation Route Cleaning √ √ √ √ √ √ √ √ √ √ √ √ Weekly   Cleaning Service
 
    ii Checking √ √ √ √ √ √ √ √ √ √ √ √ Every 3 hours   Security
 
    iii Inspection √ √ √ √ √ √ √ √ √ √ √ √ Monthly   Occupational Health
  & Safety Committee
 
    iv Damage repair                         As needed   Maintenance Unit
 
    v Lamp condition inspection √ √ √ √ √ √ √ √ √ √ √ √ Every 3 hours   Security
 
    vi Inspection to ensure unobstructed √ √ √ √ √ √ √ √ √ √ √ √ Every 3 hours   Security
  access

      vii Exit signs installation                         As needed   Occupational Health

& Safety Committee
 
    vii Installation of Signs and Education                         As needed   Occupational Health
  i & Safety Committee

    7 Socialization, Training and Simulation                             Occupational Health

& Safety Committee
  a. Socialization and Education                         As needed Awal Bros Batam & Education &
Hospital Training Unit
  b. Fire Safety Training (Occupational Health √ √ √ √ √ √ √ √ √ √ √ √ Monthly
and Safety Training)
 
c. Simulation                          

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NO ACTIVITY ACTIVITY MONTH FREQ LOCATION PIC
SUBJECT
  Fire Drill √ √ √ √ √ √ √ √ √ √ √ √ Monthly

  Evacuation Simulation                       √ Annually

8 Establishment of Smoke-Free Zone                              

  Monitoring √ √ √ √ √ √ √ √ √ √ √ √ Every 3 hours Awal Bros Batam Security

Hospital
Care Reporting                         Every case All Employees

Reprimanding                         Every case Human Resource

Department &
Occupational Health
& Safety Committee

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 Smoking Prohibition around Renovation                         Every Occupational Health
  Areas renovation & Safety Committee

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 CHAPTER VIII

EVALUATION OF ACTIVITY IMPLEMENTATION AND REPORT

1. Implementation Evaluation and Report

Program evaluation is organized every three months alongside the making of program
evaluation reports, i.e., within periods of January to March, April to June, July to
September, and October to December every year.

2. Report
Activity implementation evaluation report is managed in 2 steps:

a. Step 1 Quality Indicator and Improvement report of Fire Safety Program: is reported
monthly by the Occupational Health and Safety Committeeto the Director and
acknowledged by the Quality and Patient Safety Committee, and is presented in front
of all Coordinator/Ward/Unit Leader.
b. Step 2 program implementation evaluation is reported every three months, i.e., within
January to March, April to June, July to September, and October to December. The
report is released no later than the second week of the following month by the
Occupational Health and Safety Committee by collecting checklist data, daily report,
monthly report, and incident report, which is reported to the Quality and Patient Safety
Committee, Hospital Director, and Hospital Owner.

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 CHAPTER IX

ACTIVITY DOCUMENTATION, REPORTING, AND EVALUATION

1. Documentation
Documentation regarding Hazardous Materials and Waste Management Program is
organized based on activity schedule:

a. Daily : Checklist
b. Monthly : Quality Indicator Data, Quality Improvement
c. Incidental : Incident reports

2. Activity Reporting and Evaluation

Activity implementation evaluation report is managed in 2 steps:

1. Step 1 Quality Indicator and Improvement report of Fire Safety Program: is

reported monthly by the Occupational Health and Safety Committeeto the
Director and acknowledged by the Quality and Patient Safety Committee, and is
presented in front of all Coordinator/Ward/Unit Leader.
2. Step 2 program implementation evaluation is reported every three months, i.e.,
within January to March, April to June, July to September, and October to
December. The report is released no later than the second week of the following
month by the Occupational Health and Safety Committee by collecting checklist
data, daily reports, monthly reports, and incident reportsreported to the Quality
and Patient Safety Committee, Hospital Director, and Hospital Owner

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 CHAPTER X
ACTIVITY PROGRAM COST
The cost of the 2021 fire safety program is taken from the 2021 General Affairs Department
budget.

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 CHAPTER XI
ACKNOWLEDGEMENT

This program is designed as a reference for all working units in Awal Bros Hospital X to plan a
fire safety program in 2021. Should there be obstacles and difficulties during the implementation
of this program, we hereby, as Occupational Health and Safety Committee, humbly accept
positive inputs as an evaluation for this program to hopefully shape a far better program in the
following years.

Pekanbaru, December 28th, 2020

Prepared by Acknowledged by

Samuel Clinton, SKM dr. Jimmy Kurniawan, MKK

Head of Occupational Health and Safety Director

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