Fire Life Safety
Health Care
Services
Research
Academic
Business
On
Off
On
Off
On
Off
On
Off
Campus Campus Campus Campus Campus Campus Campus Campus
Training
Develop and maintain content
for Fire Safety Training - both
online and classroom.
Review compliance through
reports - all employees must
take this training - biannual
Online - unlimited capacity
Classroom capacity: 4 classes
per year
Quality Indicator or
KPI
DataSource
Online training accessible
24/7 Dept classroom
training on request within 1
work week
Compliance report
Target
100% employees
Report to
UTMBCompliance office
Frequency of Report
Annual or once/2YEAR
Quality Indicator or
KPI
Deliver 100% or all
requested "hands-on"
classes
Hands On Fire Extinguisher
Training - all employees HAVE
THE OPPORTUNITY to take this DataSource
training
Target
Classroom capacity: 4 classes
Report to
per year
X
X
X
X
X
X
X
X
X
X
X
X
X
X (LCC
& ADC)
X
X
X
X
EHS Compliance Calendars
100% requested
Safety Committee / EOC
Frequency of Report
Annual
Quality Indicator or
KPI
1/4 of occupiable sq.
footage each quarter
Inspections
DataSource
Inspect all buildings on campus
for compliance with Life Safety
Target
code - annual capacity:
10 Buildings
Report to
1.85 million Square feet
Frequency of Report
EHS database or EHS
Compliance Calendar
95% of all occupiable
square footage
Inst. Safety & Security
Committee & Life Safety
Subcommittee
Annual
Page 1 of 4
Revised 10.6.2015
Fire Life Safety
Health Care
Services
Academic
Business
On
Off
On
Off
On
Off
On
Off
Campus Campus Campus Campus Campus Campus Campus Campus
Quality Indicator or
KPI
DataSource
Portable Fire Equipment Regulatory required monthly
Target
Portable Fire Extinguishers
inspected currentcapacity: 2800
Report to
Building Fire Alarm SystemsRegulatory required building
fire alarm system inspections
for functionality capacity: 63
building fire alarm systems
Research
100% On-campus & LCC &
ADCPFE inspected
X
X
X
X
X (LCC
& ADC)
X
X
X
X
X (LCC
& ADC)
100%monthly
EOC Committee/Life Safety
Subcommittee
Monthly
Quality Indicator or
KPI
100% on-time completion
with minimal disruption to
staff/patients
DataSource
Target
EHS database
100% annual completion
Report to
State Fire Marshal, Life
Safety Subcommittee, EOC
Committee
Frequency of Report
Annual
Quality Indicator or
KPI
inspect 100% of all safety
showers
Frequency of Report
X (LCC
& ADC)
EHS bar-code database
Frequencyof Report
Safety Showers - inspect safety DataSource
showers against ANSI
standards. Capacity: 325 safety Target
showers
Report to
X
EHS database
100% inspected annually
Safety Subcommittee / EOC
Committee
Annual
Page 2 of 4
Revised 10.6.2015
Fire Life Safety
Health Care
Services
Research
Academic
Business
On
Off
On
Off
On
Off
On
Off
Campus Campus Campus Campus Campus Campus Campus Campus
Quality Indicator or
KPI
Building Fire Sprinkler Systems
DataSource
& Annual Fire Pumps capacity:
Inspect all wet systems per
Target
NFPA Code Requirements
Capacity: 25 Fire Pumps, 32
Report to
sprinkler systems and 49
standpipes
Inspections completed ontime and within code
Completion of fire drill with
maximum training benefit
to staff in all areas
Frequencyof Report
X
X
X
X
X
X
X
X
State Fire Marshal, Life
Safety Subcommittee, EOC
Committee
Quality Indicator or
KPI
Quality Indicator or
KPI
Hot Work Permit - EHS reviews DataSource
and approves hot work (open
flame, cutting, welding, brazing, Target
etc) in all areas of UTMB.
Capacity - 25 reviews per week Report to
X
100% on-time completion
Quarterly
Frequency of Report
X (LCC
& ADC)
EHS database or
Compliance Calendars
Frequency of Report
Fire Exit Drills - Complete NFPA
code required fire exit drills in DataSource
all UTMB areas - capacity: 120
drills in healthcare (annually), Target
78 in non-healthcare areas
Report to
(annually)
X
X
X (all
areas)
EHS database or
Compliance Calendars
100% qualified drills
State Fire Marshal, Life
Safety Subcommittee, EOC
Committee
Quarterly
No service disruption due
to late permit reviews
EHS hot work tracking
database
100% reviews within 4
working days
Life Safety Subcommittee
X
Quarterly
Page 3 of 4
Revised 10.6.2015
Fire Life Safety
Health Care
Consulting–Committee Support
Construction / Renovation
Plans Review for compliance
with Fire
& Life Safety Code Attendance
at meetings & complete review
of plans within 10 days of
receipt 8-10 reviews/week capacity 8 plans review per
week
Research
Academic
Business
On
Off
On
Off
On
Off
On
Off
Campus Campus Campus Campus Campus Campus Campus Campus
Quality Indicator or
KPI
DataSource
Target
Report to
Timely completionof
reviews
Facilities /OFPC
reviews completed within 5
working days
Life Safety Subcommittee
Frequency of Report
Annual
Quality Indicator or
Fire Alarm Response - respond KPI
to fire alarm call on-campus,per DataSource
agreement with GalvestonFire
Department to minimize impact
Target
to staff, patients and visitors.
Capacity: response provided 5 Report to
work days per week
Frequency of Report
Quality Indicator or
KPI
DataSource
Life Safety Subcommittee /
Institutional Safety & Security
Target
Committee Environment of
Care Committees (4) Resource Report to
Allocations Project
Frequency of Report
X
X
X
X
X
daily/
weekly
responds to calls within 5
minutesfrom notification
X
X
X
X
X
X
X
Police Dispatch/ Fireworks
database
on-scene within 5 min
Life Safety Subcommittee
Annual
Attendance& reporting
X
X
Committee minutes
100%
Committee Chairs
Monthly
Page 4 of 4
Revised 10.6.2015