One of the most serious issues facing any hospital or healthcare facility is the threat of fire. According to the National Fire Protection Association (NFPA), about 7,000 fires in healthcare facilities are reported each year.

Risks increase when work conducted within a healthcare facility includes clinical, research and other laboratory tasks that may involve flammable liquids and other hazardous substances. In addition, the use of specialized equipment, such as lasers and other ignition sources utilized in oxygen-enriched atmospheres, increases the threat of fire. Though this threat is very real, it is far more critical in patient care areas since patients are often incapable of self- preservation.

Because of the inability to evacuate the patients/residents vertically in the building, the fire and life safety system serves as part of the whole life safety program. Code, training and equipment are all vital to healthcare fire and life safety.

Know the Codes
Understanding detection and suppression requirements is essential to protect patients, staff and facilities. When it comes to regulating the fire and life safety systems of hospitals and other healthcare facilities, the Authority Having Jurisdiction (AHJ) is designated as the authority and must review the facility in accordance with numerous life safety and fire protection standards developed by the National Fire Protection Association (NFPA). Among those codes and standards are NFPA 72, National Fire Alarm Code^®; NFPA 101^®: Life Safety Code^®; and NFPA 99, Health Care Facilities.

The U.S. Department of Health and Human Service’s Centers for Medicare and Medicaid Services (CMS) oversees the accreditation process for U.S. healthcare facilities. The accreditation agency for the federal government is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Both require compliance with the 2000 edition of the NFPA Life Safety Code.

In essence, the Life Safety Code is a set of fire protection requirements designed to provide a reasonable degree of safety from fire. It includes construction, protection, and operational features intended to provide safety from fire, smoke and panic.

The JCAHO Statement of Conditions explains how a facility must meet the requirements of the Life Safety Code. The Statement of Conditions answers whether the facility, for example, has the proper alarm system in place, and if not, how it will meet that deficiency. The requirements also include specific procedures and plans, drills, proper equipment installation and inspection, testing, and maintenance of fire alarm and fire protection systems.

Although a new Life Safety Code chapter has been added to the JCAHO Statement of Conditions (which took effect in January), healthcare facilities will notice similarities to standards already in practice.

At first glance, there appears to be a huge increase in requirements, but the new chapter is simply the NFPA Life Safety Code translated into The Joint Commission (TJC) standards language. The requirements were written to be consistent with those issued by CMS and those published in the NFPA Life Safety Code (101-2000).

Currently, hospitals are required to comply with the 2000 edition of the Life Safety Code. The new chapter has minimal impact because facilities are required to comply with the NFPA 101 Life Safety section today. The true transition is the standardization of the overlapping requirements into one common document with consistent language. The TJC reiterates: “This chapter consists of current Life Safety Code requirements found in the Environment of Care Chapter. There are no new requirements.”

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