MHHS
ENVIRONMENT OF CARE/ENGINEERING POLICY AND PROCEDURE MANUAL
TITLE:Life Safety and Fire Prevention Management Plan
CATEGORY:Engineering Services
INDEX NUMBER:LS 301
ORIGINAL DATE:June 2004
LAST REVIEW DATE:June 2004
SUPERSEDES:
1.PURPOSE
1.1TheLife Safety and Fire Prevention Management Plan at a Memorial Hermann Hospital System Facility has been developed in collaboration between the departments of Facilities Engineering, Safety, Corporate Safety, Administration and Construction Services. This plan establishes the process for the design, implementation, measurement and training, as they relate to the protection of patients, staff, visitors and property, from fire, smoke and similar hazards in accordance with all applicable required structural features of fire protection addressed in the National Fire Protection Association (NFPA) 101, 2000 Life Safety Code (LSC), the standards of the Joint Commission for Accreditation of Healthcare Organizations, and other applicable codes and regulations.
- INTENT
2.1It is the intent ofa Memorial HermannHospital System Facility to prepare, implement and continuously evaluate a Fire Prevention and Life Safety Management Plan to ensure the safety, security and quality of Service to patients, visitors and staff as well as to protect the facility and associated property.
3.SCOPE
3.1The Life Safety and Fire Prevention Management Program is designed to assure appropriate, effective response to fire emergency situations that could affect the safety of patients, staff, and visitors, or the environment of a Memorial Hermann Hospital System facility The program is also designed to assure compliance with applicable codes and regulations thus minimizing the risk of a Life Safety incident.
4.FUNDAMENTALS
4.1The hospital buildings must be in compliance with laws, regulation, and accreditation standards, including compliance with the Life Safety Code®.
4.2Deficiencies with these codes must be corrected as quickly as practical. When deficiencies cannot be corrected within a short period of time, Interim Life Safety Measures (ILSM) are considered and implemented (as appropriate) whenever patients are exposed to an increased risk of exposure to fire or products of combustion.
4.3The fire alarm, detection and suppression systems must be maintained to ensure reliableperformance.
4.4Fire safety training is an essential part of fire safety.
5.OBJECTIVES
5.1The Institutional Fire Response Plan defines the facilities methods for protecting patients, visitors, and staff from the hazards of fire, smoke and other products of combustion and its effectiveness is reviewed and evaluated annually.
5.2The fire detection and response systems are tested as scheduled, and the results (by exception or incident) forwarded to the Environment of Care® (EC) Committee quarterly.
5.3Summaries of identified problems with fire detection and response systems, NFPA® code compliance, and fire response plans, drills and operations, in aggregate, are reported to the EC Committee quarterly.
5.4The procedures used to review furnishings, draperies, bedding, and other new materials for conformance with applicable flammability standards, and the procedures are evaluated at least every three years. System specified interior standards are in compliance with all applicable fire safety standards.
5.5The scope and objectives of this plan, as well as program effectiveness and performances are evaluated annually.
5.6Fire prevention and response training includes the response to fires, at the scene of the fire, and in other locations of the facility, and the use of the fire alarm system, processes for relocation and evacuation of patients if necessary, and the functions of the building in protection of staff and patients. Staff knowledge of these issues is evaluated quarterly via the Fire Drill Process.
5.7Performance indicators for the Fire Prevention Program are reported to the EC Committee on a quarterly basis.
5.8The Institutional Fire Response Plan defines the response to fire emergencies on a facility wide basis, at the point of origin, and in other areas of the facility, as well as the specific roles and activity should patient relocation or evacuation be necessary. Unit-specific fire plans (if appropriate) are evaluated at least tri-annually, or as significant changes take place in those units.
5.9The specific roles of physicians, and other licensed independent practitioners, volunteers, students, and others are defined, both at the scene of a fire, and in other parts of the facility as appropriate to the campus.
5.10The role and use of a fire alarm system (where installed) is included in training, and staff knowledge is evaluated as part of fire drills. The results are reported to the ECCommittee at least annually (Fire Drill effectiveness).
5.11Staff knowledge of patient relocation, including compartmentation where provided and special procedures which may be used to relocate or evacuate a patient are included in drills, and staff knowledge evaluated and reported to the ECCommittee annually (Fire Drill effectiveness).
5.12Fire extinguishers are inspected monthly, and maintained annually, are positioned to be in visible locations, and are selected based on the hazards of the area in which they are installed.
5.13Automatic fire extinguishing systems, including sprinkler systems and packaged systems are tested according to applicable NFPA and AHJ standards.
6.ORGANIZATION AND RESPONSIBILITY
6.1The Quality Committee and/or Governing Bodyreceivesummary reports of activities of the Fire Safety Program from the ECCommittee. They review reports and, as appropriate, provide feedback about identified issues. They may alsorecommend (via the administrative budgeting process) capital budget expenses, as necessary, to correct Life Safety Code deficiencies, and to provide support to facilitate the ongoing activities of the Fire Safety Program.
6.2Administration receives regular reports on the activities of the Fire Safety Program from the EC Committee. The Administrative Team reviews information and, as necessary, communicates concerns about key issues and regulatory compliance to Facilities Engineering and/or the Safety Committee Chair. The Administrative Team collaborates with Facilities Engineering/Safety to establish operating and capital budgets for the Life Safety and Fire Prevention Program.
6.3Facilities Engineering and the Safety Officer manage the Fire Safety and Response Program. They identify Life Safety Code deficiencies, develop Plans for Improvement, manage the maintenance of fire systems, the fire plan, fire drills, and fire response. Hospital Education and Human Resources department facilitates training of staff, volunteers, and physicians. Facilities Engineering and the Safety Officer advise the ECCommittee regarding fire safety issues which may necessitate changes to policies, orientation or education, or purchase of equipment.
6.4Department heads orient new staff members to the department-specific and, as appropriate, to job- specific fire safety procedures. Department heads are responsible for ongoing training of their staff in fire safety procedures. When necessary, Facilities Engineering and/or the Safety Officer provides department heads with assistance in developing department fire safety procedures.
6.5Individual staff members are responsible for learning and following hospital fire plans. Individual staff members are also responsible for learning and using emergency reporting procedures for fires and fire hazards.
7.PROCESSES OF THE FIRE SAFETY MANAGEMENT PLAN
The organization manages fire safety risks (EC.5.10)
7.1Life Safety and Fire PreventionManagement Plan (EC.5.10.1)
7.1.1 A Memorial Hermann Hospital System facility has developed and maintains a written management plan describing the processes it implements to effectively manage the fire safety environment of patients, staff, and others. The management plan is evaluated annually, and modified as necessary, based on changes in conditions, regulations and standards, and identified needs.
7.2Protecting Patients Staff and Others (EC.5.10.2)
7.2.1Facilities Engineering and the Safety Officer share responsibility for managing the program for protecting patients, personnel, visitors, and property from fire, smoke, and other products of combustion. The fire protection program includes three phases.
7.2.1.1The first is design of buildings and spaces to assure compliance with current local, state, and national building and fire codes. A Memorial Hermann Hospital System facility employs qualified architects and engineers to develop building and fire protections system designs. All designs are reviewed by local or state agencies as a part of the construction and permitting process. A construction monitoring and building commissioning program round out the design phase.
7.2.1.2The second phase is maintenance of the current facility. Facilities Engineering is responsible for setting maintenance standards based on applicable codes. The standards are applied through a process of planned maintenance and management of the work done by facility staff and contractors to ensure the end product of all work maintains or improves the level of life safety in each affected area.
7.2.1.3The third phase is an active program of fire prevention, fire safety, and fire response training. The Facilities Engineering and Safety Committee process facilitate this phase of the program.
7.3Fire Detection and Response System Tests and Inspections (EC.5.10.3)
7.3.1Facilities Engineering is responsible for maintenance of the Fire Detection and Response Systems, including (as appropriate to each facility):
7.3.1.1All supervisory signal devices (except valve tamper switches)
7.3.1.2All valve tamper switches and water flow devices
7.3.1.3All duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors
7.3.1.4Occupant alarm notification devices, including all audible devices, speakers, and visible devices,
7.3.1.5Off-premises emergency forces notification transmission equipment
7.3.1.6Fire pumps
7.3.1.7Water storage tank high- and low-water level alarms.
7.3.1.8External Water storage tank low-water temperature alarms
7.3.1.9Main drain tests
7.3.1.10Fire department connections
7.3.1.11Fire pumps
7.3.1.12Kitchen automatic fire-extinguishing systems
7.3.1.13Carbon dioxide and other gaseous automatic fire-extinguishing systems
7.3.1.14Portable fire extinguishers
7.3.1.15Standpipe occupant hoses
7.3.1.16Standpipe systems
7.3.1.17Fire and smoke dampers
7.3.1.18Automatic smoke-detection shutdown devices for air-handling equipment
7.3.1.19Horizontal and vertical sliding and rolling fire doors
7.4Fire Response Plan (EC.5.10.4)
7.4.1The Institutional Fire Response Plan provides clear, specific instructions for staff responding to an emergency. The procedures provide information about notifying appropriate administrative staff of the emergency and actions to take to protect patient safety. Each department head is responsible for maintaining copies of emergency procedures in a continuously accessible location.
7.4.2The head of each department serving patients is responsible for developing and training staff about department specific emergency fire response procedures. Each department head is responsible for providing department and area personnel with an orientation to emergency procedures related to their job. Additional department level training is provided on an annual basis as part of the continuing education program or on an as- needed basis. Each department head is responsible for reviewing department specific (if appropriate) Fire Safety Program emergency procedures annually.
7.5Fire Plan Elements
7.5.1The roles of all employees, medical staff, volunteers and students at and near the point of fire origin are defined. The basic plan in the hospital is based on the acronym “RACE”:
7.5.1.1Rescue anyone directly affected by the fire
7.5.1.2Alarm by pulling fire alarm pull stations, and calling (Your number) on the phones
7.5.1.3Contain or Close Doors to contain smoke and the products of combustion
7.5.1.4Extinguish, and as needed prepare to relocate patients
7.5.2The roles of all employees, medical staff, LIP, volunteers and students are defined in the Institutional Fire Response Plan.
7.5.3If a relocation or evacuation is deemed necessary, staff should follow directions of their Institutional Fire Response and Evacuation/Emergency Response Plans.
7.6Processes to Control Flammability of New Acquisitions (EC.5.10.5)
7.6.1Facilities Engineering, Architecture and Construction, Project Management Team and Materials Management are responsible for managing the program to define the requirements that furniture and furnishings, including bedding, window draperies, and other curtains, furnishings, decorationsare expected to meet prior to purchase. A MemorialHermannHospital System facility has written product specifications that are detailed in the Interior Finish Standards Program that are maintained by System Architecture and Construction and are applicable System-wide..
7.7Life Safety Code® NFPA 101, 2000 edition(EC.5.20)
7.7.1Facilities Engineering and Architecture and Construction are responsible for managing the program for complying with codes and standards.
7.7.2Memorial Hermann Hospital System facilities are maintained in compliance with the Life Safety Code (NFPA 101, 2000 edition). Compliance is maintained by ongoing inspection and preventive maintenance of key elements.
7.7.3Where significant code violations are identified, they are corrected promptly, or if the correction time will exceed 30 days the plan for improvement will be documented as part of the Statement of Condition’s™ (SOC™) Plan for Improvement (PFI). As issues are corrected, they will be noted as such and on a quarterly basis, status of the SOC will be reviewed as appropriate. If tasks will not be completed as scheduled, a determination must be made as to whether the delay will be sufficient to justify a letter to JCAHO® notifying of the change in plans. This determination will be made by the Facilities Engineering, and the Safety Officer, and reviewed by Administration.
7.7.4Facilities Engineering is responsible for the SOC document. The Plan for Improvement is used to develop project budgets.
7.8Fire drills (EC.5.30)
7.8.1Fire drills are a critical tool to maintain the readiness of staff to respond to a fire emergency, to minimize the likelihood of injury to patients, visitors and staff. Staff participation is necessary to maintain a level of readiness, and staff knowledge of the equipment and procedures they must follow to protect themselves and their patients. To evaluate staff knowledge, drill activities are observed, and staff is questioned about their role and activities during a fire emergency nearby and elsewhere in the building.
Fire drills are conducted in all hospital and ambulatory healthcare facilities on each occupied shift each quarter, and evaluated and critiqued on a randomly selected basis to assure that all elements of the drill activity are exercised in all occupied areas.
7.8.2Fire drills are conducted in all otherMemorial Hermann Facilities (Business Occupancy) at least once a year exercising the applicable elements of the facilities’Fire Response Plan.
7.8.3Fire drills will normally be unannounced, with the exception of those done as corrective training activities. Actual incidents may be treated as a fire drill as long as all elements of the facilities Fire Response Plan are exercised.
7.8.4All staff in the affected areas are required to participate in the drills to the extent that facilities Institutional Fire ResponsePlan describes. This includes all hospital staff, and all Memorial Hermann Hospital System facility staff in buildings where space is shared with others.
7.8.5Fire drills are observed, documented on a formatted data collection form and critiqued to identify opportunities to improve, and areas where additional training would be appropriate. In addition, fire response knowledge is evaluated by ongoing questioning during environmental tours.
7.8.6The results of the critique and evaluation of drills and evaluation of staff knowledge are used to identify improvements needed in training programs, equipment, and administrative compliance issues. Such improvements are included in monitoring activities, and the results used to identify the effectiveness of the activities to improve fire safety. Summary reports of these outcomes (effectiveness) are trended and reviewed on a periodic basis by the EC Committee.
7.8.7Staff knowledge and response to drills is evaluated by a data collection document that includes:
7.8.7.1How, and under what conditions they activate the fire alarm, device or telephone response number.
7.8.7.2When it would be necessary to call 911 to alert the Fire Department
7.8.7.3Their containment of fire and smoke, where appropriate
7.8.7.4How they would move patients to areas of refuge (adjacent fire zones)
7.8.7.5How they would use fire extinguishers, and when
7.8.7.6Specific duties such as shut-off of oxygen valves, or other emergency responses
7.8.7.7What they would do if a building evacuation was announced.
7.9Maintaining fire-safety equipment and building features (EC.5.40)
7.9.1Fire Alarm and Related Systems
Facilities Engineering is responsible for maintenance of the fire alarm and related systems. Corrective and preventive maintenance to the fire alarm is performed by competent fire alarm system vendors who perform the scheduled maintenance of all components of the fire alarm. This Team documents their work with forms developed by the contractor and hospital-generated work orders. A testing matrices and corresponding standard operating procedures outline the specific testing and maintenance requirements of each facility. Results (by exception or incident) are communicated to the EC Committee and senior leadership as appropriate.
7.10Interim Life Safety Measures (ILSM) (EC.5.50)
7.10.1Facilities Engineering and Architecture and Constructionare responsible for managing the ILSM program. The program is applied to situations when the assessments of the life safety deficiencies identified in the existing building or occur as part of construction indicate the need.
7.10.2An assessment tool is used to evaluate specific situations to determine if the degree of deficiency warrants an ILSM and what specific measures are required to mitigate the effects of the deficiency. This is also a component of the preconstruction risk assessment process. Where any facility, Life Safety system, or construction deficiency is identified, the 11 key elements of the ILSM are evaluated, and as applicable, the appropriate ILSM implemented.
7.10.3Facilities Engineering and Safety are responsible for communicating the findings to appropriate managers, staff, contractors, and senior leaders. In addition, they are responsible for monitoring implementation of the ILSM and taking action when the required actions are not being observed.
7.10.4The schedule of monitoring and documentation is determined on a per project basis. The Project Team is responsible for maintaining all ILSM documentation from the onset through elimination of the deficiencies. Regular reports of ILSM activities will be made to the ECCommittee.
7.11Improving conditions in the Environment of Care®(EC.9.10 – EC.9.30)
7.11.1Reporting of Environment of Care Issues (EC.9.10.1)
7.11.1.1Facilities Engineering makes quarterly reports of problems, failures, and user errors to the EC Committee. The reports summarize findings of incident reports, maintenance and repair activities, hazard notices and recalls, and other information of interest.