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  • pg 1
									                                             1SO 14001 & OHSAS 18001 FAQ
         S/N                                 ITEM TO CHECK                                           AUDIT   REMARKS
                                           QEHS Policy (Clause 4.2)
          1.1 Briefly explain the QEHS Policy
              > Refer to NUH Quality Policy

          1.2 How is the policy disseminated to you?
              > QEHS Intranet
              > QEHS Manual
              > NUH Basics Card
              > NUH Quality Policy Display in Department
              > Posters
          1.3 How is the policy made available to interested parties?
              > Through internet
              > Service agreement (for example)
          1.4 How often is the policy reviewed?
              > Policy is reviewed during annual management review meeting
              Notes: a) All employees should be aware of the NUH Quality Policy
          2.0            Hazard Identification and Risk Assessment (Clause 4.3.1)
          2.1 How do you conduct hazard identification?
              > Explain each column in the Hazard Identification Form
              > Explain the definition of Hazards
              > Review completeness of Hazard Identification Form
              > Ensure non-routine activities are captured in Hazard Identification Form
              > Ensure all activities conducted by department are listed in the Hazard
              Identifcation Form
          2.2 How are all hazards identified being reviewed for significance?
              > Explain the severity, likelihood and risk columns
          2.3 How the organization defines significant hazard?
              > Explain the significant criteria table: a) Risk No., b) Emergency rating, c) Legal
              implications, d) Affecting NUH's reputation

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                                           1SO 14001 & OHSAS 18001 FAQ
         S/N                                ITEM TO CHECK                                         AUDIT   REMARKS
          2.4 When is the hazards identification form updated?
              > Where there is a change in processes, equipment or material used
              > When new hazards have been identified in Hazard Identification Form and fulfill
              the criteria for Significant Hazards. The updated Register of Significant Hazard
              must be submit to Hazard Workgroup for review.
              > Interview QEHS Hazard Identification Workgroup
          2.5 What are the significant hazards in your department?
              > Refer to the Department's Register of Significant Hazards

          2.6 How are staff made aware of these significant hazards?
              > Randomly select staff to interview

          2.7 What are the control measures taken for ALL significant hazards?
              > Refer to Register of Significant Hazards Form and explain what control
              measures has been put in placed
              Notes : a) Register of Significant Hazards must be completed and submitted to
              NUH ORMC Workgroup
                               Legal and Other Requirements (Clause 4.3.2)
          3.1 What are the relevant requirements applicable to your departments?
              > Refer to QEHS Legal Register and explain some of the requirements (WSHA,
              Radiation Protection Act, Fire Safety Act, etc)
              > Verify if the latest legal updates has been included and issued to related
          3.2 How are these requirements communicated to staffs?
              > Randomly select staff to vertify on waste disposal requirements and other
              applicable legal requirements

          3.3 How are updated legal requirements disseminated to each department?

               > Updates are received through RIET and reviewed by QEHS Legal Workgroup

              > Interview the QEHS Legal Workgroup
              > Disseminate through e-mail to affected departments and request reply via
              QEHS Legal Action Plan Form by all departments
          3.4 How does the organization continue to ensure that the legal requirments
              are compiled?
              > Key parameters to demonstrate legal compliance are captured in the QEHS
              Performance Monitoring Matrix and measured at specified intervals.
              > During periodic inspection, the legal register is used as a checklist for

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                                            1SO 14001 & OHSAS 18001 FAQ
         S/N                                 ITEM TO CHECK                                      AUDIT     REMARKS
          3.5 How do you ensure that the organization continue to comply with the legal
              > Key parameters are captured in the QEHS performance monitoring matrix and
              periodic measurements is conducted
              > Periodic inspection is conducted to verify compliance status

                > Interview QEHS Audit & Inspection Wokgroup
                Note: a) Legal register must be updated, b) Quarterly update and review must
                be done, c) Relevant permits and licenses must be retrievable, d) Legal
                requirements such as poison act, medicine act are also updated into register

                                  Objectives and Programs (Clause 4.3.3)                                EMR, OHSMR
          4.1 What are the QEHS objectives set by the organization and how do you
              intent to achieve them?
              > Show the QEHS Improvement Program sheet
              > Interview the program owners
              > Explain the details of the program
          4.2 Where are the evidences to display activities are carried out as planned?

              > Show actual monitoring results such as training records, measurement records,
              measuring instruments etc.
          4.3 How are these programs monitored to ensure that they are effective?
              > Show actual monitoring results based on performance indicators / targets
              > Show minutes of Management Review meeting minutes on review of program
              Note: a) Performance indicators must be monitored to demostrate achievement
              of targets
                               Structure and Responsibility (Clause 4.4.1)
          5.1 What is the structure adopted for the implementation of QEHS management
              > Show the QEHS organization structure
              > Interview the workgroup members regarding their responsibilities
          5.2 Who & what is the responsibility of the EMR, OHSMR?
              > Refer to the NUH Quality Manual
              > Interview EMR, OHSMR
          5.3 How are issues that require management commitment escalated up for
              > Through Quality Forum and Management meetings
              > Review minutes of the meetings
          5.4 What is the responsibility of QEHS Officer?
              > Interview the Safety Officer
          5.5 How are roles, responsibilities and authorities of personnel documented
              and communicated?
              > Through NUH Quality Manual and appointment letters
              > Interview some staff
          5.7 How does the management provide adequate resources essential for the                      Appointment of
              implementation and control of the QEHS management system?                                 EMR & OHSMR
              > Through timely and effective implementation of corrective actions for QEHS
              > Show results of actions taken and programs implemented.

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                                            1SO 14001 & OHSAS 18001 FAQ
         S/N                                 ITEM TO CHECK                                  AUDIT   REMARKS
                           Training, Awareness and Competence (Clause 4.4.2)
          6.1 How are the training needs of staff identified in the organisation?
              > Through annual training needs analysis (TNA) exercise
              > Show TNA
          6.2 Has appropriate training been provided to all personnel whose work may
              create impact on QEHS at the workplace?

              > Staff who handle chemicals and / or are exposed to excessive noise
              should receive specific QEHS training
              > Though internal (e.g. MSDS, Noise-Induced Deafness training programmes) /
              external training programs
              > Show training and attendance records
          6.3 What are the QEHS training programs identified?
              > Core and specific training courses identified
              > Interview EMR and OHSMR
                               Consultation & Communication (Clause 4.4.3)
          7.1 Is there a platform for internal communication between all levels and
              functions regarding QEHS issues?
              > Top-down communication through intranet, newsletters, emails, QEHS
              Committees, CEO Townhall, etc
              > Bottom Up communication through email, CEO Townhall, etc
          7.2 How are external feedback being handled?
              > Customers and patients feedback go to PRD for consolidation
              > External feedback from authorities such as MOM, ENV, MOH and public
              concerned go to individual department and a copy is archived at PRD
              > Interview PRD and review external communication records
                                       Documentation (Clause 4.4.4)
          8.1 What is the documentation structure for the QEHS management system?

              > NUH Quality Manual
              > Departmental Procedure Manuals & SOPs
          8.2 What is the inter-relation between the procedures and the QEHS
              > Refer to the inter-relation matrix or reference in the NUH Quality Manual
          8.3 What are the procedures relating to QEHS management system?
              > Verify procedures have been updated and meet requirements

                                      Document Control (Clause 4.4.5)
          9.1 How is the documentation numbering system being defined?
              > Refer to the document numbering procedures (forms control, control of
              documents, control of records)
          9.2 How are the legal register being updated and controlled?
              > Verify to ensure the latest copy of update is available
              > Interview QEHS Legal Workgroup
          9.3 Are the documents controlled?
              > Refer to the QEHS e-DCS system
              > Interview OORG

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                                            1SO 14001 & OHSAS 18001 FAQ
         S/N                                 ITEM TO CHECK                                           AUDIT   REMARKS
                                      Operation Control (Clause 4.4.6)
              What are the hazardous tasks in the department and are there safe work
         10.1 instructions developed?
              > Examples of hazardous tasks involving use of machines, application of heat, fall
              from height, use of cutting tools or radioactive machines/substances, handling
              chemicals, exposure to excessive noise
              > Verify that safe work instructions are developed for such tasks
         10.2 Are there hazardous materials being used?
              > Verify availability of SDS
              > SDS Summary Sheet
              > Storage locations and handling practices
              > Availability of appropriate PPE
         10.3 Are the machines or systems being maintained?
              > This includes facilities such as cooling towers, chillers, boilers, exhaust
              ventilation system etc
              > Inspection reports from authorities
              > Records for the implementation of Lock Out Tag Out (LOTO) procedures and
              maintenance of LOTO
              > Maintenance of medical equipment and its related safe work instructions
              > Proper disposal of different types of wastes (general, biohazard, cytotoxic, toxic
              industrial etc)
         10.4 How are contractors and vendors being managed?
              > Briefings for contractors
              > Service agreement
              > Conducting regular second party inspection
                           Emergency Preparedness and Response (Clause 4.4.7)
          11.1 How are the emergency situations identified and what are the potential
               > Interview OSS ERT

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                                            1SO 14001 & OHSAS 18001 FAQ
         S/N                                ITEM TO CHECK                                          AUDIT   REMARKS
          11.2 What are the response required for each potential situation?
               > Verify response against procedures
               > Verify training of ERT team members
               > Interview ERT team members

          11.3 How does the organization prepare for such situation?
               > Verify the availability of PPE and mitigating equipment. Ensure they are in
               working order and not expired
          11.4 How are such response plans being tested for effectiveness?
               > Verify drill records and actions taken to improve response
               > Ensure related documents are updated
          11.5 How are staff kept informed on the emergency situation and how do they
               informed the ERT when such situation arise?
               > Verify the briefing records by champions and ensure the availability of
               emergency response contact numbers listing
               > Verify with FCC (Fire Command Centre) staff to ensure that they understand
               the procedures
               > Verify the emergency response contact numbers listing is updated
                          Performance Measurement and Monitoring (Clause 4.5.1)
         12.1 How are QEHS performance measurements requirements identified?
              > Based on legal requirement, significant hazard list and other concerns raised by
              > Verify the QEHS Performance Monitoring Matrix
         12.2 What are the internal measuring instruments used?
              > Verify to ensure such instruments are calibrated
              > Verify calibration results
         12.3 What are the actions taken when monitoring results are non-conforming to
              standard requirements?
              > Corrective actions will be initiated
              > Review all measurement data and verify that appropriate actions are taken for
              non-compliance situations
         12.4 How are performance standards set?
              > Based on legal requirements. Example: PEL (Permissible Exposure Limit)
              > Based on historical data and standards will be set based on the data
         12.5 How are such monitoring results being reviewed?
              > Results are compiled on a regular basis and reported in QEHS MR committee
              meeting and annually in management review meeting

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                                            1SO 14001 & OHSAS 18001 FAQ
         S/N                                ITEM TO CHECK                                       AUDIT   REMARKS
                 Accidents, Incidents, Non-conformance and Corrective and Preventive
                                             actions (Clause 4.5.3)
         13.1 How are incidents and nonconformance reported?
              > Verify incident reporting (e-HOR)
              > Monitor to ensure appropriate actions have been taken for situation reported

              > Verify with PRD with e-HORs raised that are related to EHS incident
         13.2 How are corrective actions implemented throughout the organization once
              they have been verified to be effective?
              > Verify to ensure that affected procedures are updated
              > Ensure that timely verification of effectiveness is done
                             Records and Records Management (Clause 4.5.4)
          14.1 What are the QEHS records applicable?
               > Check with departments and ensure they keep the master list of Quality
               > Ensure that the forms used have been issued with the appropriate form number

         14.2 How are records being kept?
              > Verify the records keeping are in accordance with the record master list
                                            Audit (Clause 4.5.5)
          15.1 What are the types of audits conducted?
               > QEHS internal audits and periodic safety inspections
          15.2 How are the audits planned and executed?
               > Verify audit schedules and review actual audit report
               > Ensure auditors are independent of areas audited
               > Ensure all findings are closed in a timely manner
               > Interview MRs
                                       Management Review (Clause 4.6)
          16.1 What is being reviewed during Management Review?
               > Verify with concerned Management Review procedures and Management
               Review Meeting minutes
          16.2 What is the frequency of Management Review?
               > Verify with procedure Internal Audit

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