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Fire Safety Management Plan
2015
I. EXECUTIVE SUMMARY
The Environment of Care (EC) and the physical condition of occupants poses unique fire safety risks to the patients served, the employees and medical staff who use and manage it, and to others who enter the environment of the {{Organization}}. The fire safety program is designed to identify and manage the risks of the environments of care operated and owned by the organization. The specific fire safety risks of each environment are identified by conducting and maintaining a proactive risk assessment.
II. SCOPE
The Fire Safety Management Plan describes the risk and daily management activities that the organization has put in place to achieve the lowest potential for adverse impact on the safety and health of patients, staff, and other people, coming to the organization’s facilities. A fire safety program based on applicable laws, regulations, codes, standards, and accreditation standards is designed to manage the specific risks identified in each healthcare building or portions of buildings housing healthcare services operated by the organization.
This plan covers activities performed in the various locations of the organization, including the {{hospital campus, clinics and physician’s practices, nursing homes, and other appropriate operations center}}.
III. PRINCIPLES
A. All buildings of housing patient care services must be designed, operated, and maintained to comply with the 2000 edition of the Life Safety Code.
B. All fire alarm, detection, and extinguishing systems and equipment must be maintained to comply with applicable codes and standards.
C. All staff must be educated and trained to respond effectively to fire, smoke, or other products of combustion to minimizing the potential of loss of life or property in the event of a fire.
D. Appropriate temporary administrative and engineering controls must be designed, implemented, and maintained whenever existing deficiencies or conditions created by construction activities significantly reduce the level of life safety in any area where patients are cared for or treated.
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The Objectives for this Plan are determined from the annual evaluation of the previous year’s management plan and the results of other activities that include environmental tours, risk assessment information collected and evaluated during the year, and special incidents.
The Objectives for the Plan are: {{suggestions below}}
Review and revise the Fire Response Plan to cover the new Off-site Clinics Complete the installation of the new fire alarm system Conduct fire extinguisher refresher training of Emergency Room staff
V. PERFORMANCE ACTIVITIES
One part of determining the effectives of the Program is by selection and monitoring specific performance measures. Performance measures are established to determine the opportunity for action to improvement in the Program. This can include staff knowledge questions, staff or equipment performance, and items identified from the organization’s risk assessment. These measures include a denominator and numerator for determining performance
The performance measures for the Program are: {{Suggestions below}}
Percent of correct response for Staff knowledge: How to report a fire (Threshold = 95%) Percentage of responders that arrived at the location of the fire drill in the require time (Threshold = 100%)
VI. PROGRAM MANAGEMENT STRUCTURE
A. The {{Fire Safety Manager}} assures that an appropriate maintenance program is implemented. The manager of the program also collaborates with the Safety Officer to develop reports of performance for presentation to the {{Environment of Care Committee, Safety Committee, etc}} on a quarterly basis. The reports summarize organizational experience, performance management and improvement activities, and other fire safety issues.
B. The facilities management technicians and selected outside service company staff schedule and complete all calibration, inspection, and maintenance activities required to assure safe reliable performance of fire safety equipment in a timely manner. In addition, the technicians and service company staff perform necessary repairs.
C. Individual staff members are responsible for being familiar with the risks inherent in their work and present in their work environment. They are also responsible for implementing the appropriate organizational, departmental, and job related procedures and controls required to minimize the potential of adverse outcomes of care and workplace accidents.
D. The Board receives regular reports of the activities of the program from the Committee. The Board reviews the reports and, as appropriate, communicates concerns about identified issues back to the manager of the FSM and appropriate clinical staff. The Board collaborates with Leadership and other senior managers to assure budget and staffing resources are available to support the program.
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VII. ELEMENTS OF THE FIRE SAFETY MANAGEMENT PLAN
EC.01.01.01-EP6 – Fire Safety Management Plan
The Fire Safety Management Plan describes the procedures and controls in place to minimize the potential that any patients, staff, and other people coming to the facilities experience an adverse outcome in the event of a fire.
EC.02.03.01-EP1 – Processes for Protecting Building Occupants and Property
The {{Fire Safety Manager}} is responsible for coordinating the development of design, operations, maintenance, and training processes to minimize the potential for fires and of adverse consequences related to the presence of fire, smoke, or other products of combustion.
Design
The {{Fire Safety Manager}} collaborates with qualified design professionals, code enforcement, and facility licensing agencies to assure that buildings and spaces are designed to comply with local, state, and national building and fire codes. The Manager assures that all required permits and inspections are obtained or completed prior to occupancy. The Manager maintains all plans, inspection reports, and other documents related to the design and construction of any building or space housing patient care or treatment services.
Management
The Manager oversees the design, implementation, and documentation of processes designed to assure optimal performance and continual compliance with code requirements of fire alarm, detection, and suppression systems. Similar programs are in place for maintenance of building elements operating conditions that play a role in the fire safety level of the environment.
The Manager is responsible for assuring that all renovation and new construction within existing buildings is done in a manner that preserves compliance with codes and standards.
Fire Response Process
The {{Fire Safety Manager}} is responsible for the design and management of a fire response plan that meets the unique needs of the occupants of each department or services. The current fire response plan is based on the R.A.C.E. principle. Area specific response and evacuation plans that include training and equipment required to manage unique risks identified in areas are in place. The plans are evaluated annually as part of the overall program review.
EC.02.03.01-EP2 – The organization prohibits smoking except in specific circumstances
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A smoking policy has been developed that is consistent with the current The Joint Commission requirements. The policy prohibits smoking in any hospital building by staff, visitors, underage patients, and ambulatory patients. The policy also prohibits smoking in areas where smoke could enter the organization buildings. The procedures for managing the use of smoking materials are followed and enforced by all managers and staff, and documented in the Environmental Tours process.
In the event the administrative and medical staff leadership determines that there is a need to permit patients to smoke as part of the management of a course of treatment, a smoking area that is physically separate from care, treatment, and service areas will be prepared to safely allow designate patients to smoke. An alternative has been identified to smoking that is offered to all and resources to assist staff and patients with smoking cessation as desired have been developed.
EC.02.03.01-EP4 – The organization maintains free and unobstructed access to all exits in areas classified as business occupancy
Leaders in all areas of the organization are responsible for assuring that equipment, furniture, and supplies are not stored in corridors as required in NFPA 101, Life Safety Code. All exits in areas classified as business occupancy must also maintain access to exits free and obstructive. The condition of corridors is evaluated during each environmental rounds activity. All violations are reported to the leader of the area where the deficiency was identified. Repeated violations are evaluated to determine the probable cause and to develop a resolution.
EC.02.03.01-EP9 & 10 – The organization has a written fire response plan
The {{Fire Safety Manager}} is responsible for coordinating the implementation of the fire response plan. All staff, including Licensed Independent Practitioners, is oriented to the RACE response model and the P.A.S.S. model for effective use of portable fire extinguishers. In addition, all staff are oriented to the department or service specific plans that account for the unique challenges posed by the condition of occupants and the design of space in which they work.
The written fire response plan describes the specific roles of staff and licensed independent practitioners at and away from a fire's point of origin including:
1. when and how to sound fire alarms 2. how to contain smoke and fire 3. how to evacuate to areas of refuge
EC.02.03.03-EP1 – 5 – Conducting fire drills
Regular fire drills are conducted to reinforce training and education. At least 50% of the drills are unannounced. The frequency of drills is based on regulations and accreditation requirements. All healthcare, ambulatory healthcare, and overnight sleeping areas conduct drills at least once per shift per quarter. If conditions evaluated as part of the Interim Life Safety Measures (ILSM) indicate a need for additional drills to enhance staff awareness of degraded life safety protection in various areas, there is documentation that the additional drills are performed. All freestanding business occupancies are drilled at least once per shift per year. 4 <
All fire drills are critiqued to evaluate fire safety equipment, fire safety building features, and staff response to fire. The evaluation is documented. An aggregate evaluation of fire drills is conducted and the aggregate analysis looks for patterns or trends of deficiencies. When deficiencies are identified, there is documentation that the deficiencies are corrected.
EC.02.03.05-EP1 – 20, 25 - Inspection, testing, and maintenance of fire safety systems
The {{Fire Safety Manager}} works with qualified contractors and staff to design a program of calibration, inspection, maintenance, and testing to assure the reliability of all fire safety systems and equipment. The program includes systems and equipment such as fire sprinklers, smoke detection, fire pumps, fire dampers, doors, and shutters, and smoke control elements of the environment. Each system or piece of equipment is maintained to comply with requirements of the National Fire Protection Association or other applicable codes and standards.
When deficiencies are identified, they are corrected immediately when possible. If a deficiency cannot be corrected immediately, the Facilities Manager evaluates the impact of the deficiency using the ILSM criteria to determine if an ILSM plan needs to be put in place until the deficiency can be corrected. Any ILSM plans are monitored for effect and documentation demonstrating compliance with the plan is maintained by the Safety Officer.
EC.04.01.01-EP15 – Annual evaluation of the management plans.
On an annual basis, the organization evaluates the scope, objectives, performance, and effectiveness of the Plan to manage the risks to the staff, visitors, and patients. The findings of the annual review are used to develop the management plan for the following year. The annual evaluation is presented to the EC Committee for review. . LS.01.01.01-EP1 – 3 – Life Safety Management
The {{Fire Safety Manager}} is responsible for assessing compliance of the organization with the Life Safety Code, complete the electronic Statement of Condition (eSOC) and manage the resolution of deficiencies identified. A quarterly report of the rate of completion of any Plan for Improvement is prepared for the EC Committee. The organization maintains a current electronic Statement of Conditions (eSOC). Note: the eSOC is available to each organization through The Joint Commission Connect extranet site. When the organization plans to resolve a deficiency through a Plan for Improvement (PFI), the organization meets the time frames identified in the PFI accepted by The Joint Commission. The organization maintains documentation of any inspections and approvals made by state or local fire control agencies.
LS.01.02.01-EP1 – 14 – Management of fire safety risks
The organization notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented. In addition, the organization posts signage identifying the location of alternate exits to everyone affected.
The organization has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the organization follows special measures to compensate for increased life safety risk. A program
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The {{Fire Safety Manager}} is responsible for monitoring the effectiveness of the implementation of the appropriate ILSM. When deficiencies are identified, the appropriate actions are taken to resolve the deficiencies. All monitoring and actions to resolve deficiencies related are documented. The documentation is presented to the EC Committee as part of the quarterly fire safety management report to the Committee. All ILSM evaluations, plans, and monitoring documentation are maintained for at least three years.
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