Community Health Center Template
Fire Management Plan
Safety Policy and Procedure
Fire Safety Management Plan
I
PURPOSE
The Fire Prevention Management plans provide for a fire-safe environment for the delivery
of patient care and other necessary functions. The appropriate fire detection and response
systems, plans for staff response to fire situations; systems tests, inspections, and drills help
assure that all plans and systems will function properly when required. The Board of
Directors of <your chc> authorizes and supports the establishment and maintenance of an
effective clinic-wide Fire Prevention program.
The purpose of the Fire Prevention Plan is to protect building occupants from fire and the
products of combustion.
II
SCOPE
The Fire Safety 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 <your chc>. The program is also designed to assure compliance with
applicable codes and regulations.
The program is applied to <your chc> and <your satellite locations if applicable>.
Ill
FUNDAMENTALS
A. The hospital buildings must be in compliance with law, regulation, and accreditation,
including compliance with the 2000 Life Safety Code®.
B. Deficiencies 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 whenever patients are exposed to an
increased risk of exposure to fire or products of combustion.
C. The fire alarm, detection and suppression systems must be maintained to ensure
reliable performance.
D. Fire safety training is an essential part of fire safety.
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IV
OBJECTIVES
A. The Fire Plan defines the hospital's methods for protecting patients, visitors, and staff
from the hazards of fire, smoke and other products of combustion and is reviewed and
evaluated annually.
B. The fire detection and response systems are tested as scheduled, and the results
forwarded to the Safety Committee quarterly.
C. Summaries 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 Safety Committee quarterly.
D. The procedures used to review furnishings, draperies, and other new materials for
conformance with applicable flammability standards, and the procedures are evaluated at
least every three years.
E. The scope and objectives of this plan, as well as program effectiveness and
performances are evaluated annually.
F. Fire 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.
G. Performance indicators for the Fire Prevention Program are reported to the Safety
Committee on a quarterly basis.
H. The Fire 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 are
evaluated at least tri-annually, or as significant changes take place in those units.
I.
The 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.
J. The 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 Safety
Committee at least annually.
K. Staff knowledge of patient relocation, including compartmentation where provided, and
equipment which may be used to relocate or evacuate a patient are included in drills, and
staff knowledge evaluated and reported to the Safety Committee annually.
L. Fire 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. Automatic fire extinguishing systems, including sprinkler systems and
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packaged systems are tested according to applicable NFPA standards. Tests are
annual or semiannual, depending on system function.
V
ORGANIZATION AND RESPONSIBILITY
A. The Board of Directors receive regular reports on the activities of the Fire Prevention
Program from the Safety Committee. The Board of Directors review reports and, as
appropriate, communicates concerns about identified issues and regulatory compliance.
The Board of Directors authorizes capital budget expenses, as necessary, to correct Life
Safety Code deficiencies, and to provide support to facilitate the ongoing activities of the
Fire Prevention Program.
B. The Executive Vice President receives regular reports on the activities of the Fire
Prevention Program. The Executive Vice President reviews reports and, as necessary,
communicates concerns about key issues and regulatory compliance to the Director of
Facilities or <designee>. The Executive Vice President collaborates with the Director of
Facilities or <designee> Operations to establish operating and capital budgets for the Fire
Prevention Program.
C. The Director of Facilities or <designee> is responsible for joint management of the Fire
Prevention Program. He is responsible for identification of Life Safety Code deficiencies,
development of Plans for Improvement, maintenance of fire systems, the fire plan, fire
drills, and fire response. Training of staff, volunteers, and physicians is facilitated by the
Human Resources Department or <designee>. The Director of Facilities or <designee>
advises the Safety Committee regarding fire safety issues which may necessitate changes
to policies, orientation or education, or purchase of equipment.
D. Department heads are responsible for orienting new staff members to the department and,
as appropriate, to job specific fire safety procedures. Department heads are responsible
for training their staff in fire safety procedures. When necessary, the Director of Facilities
or <designee> provides department heads with assistance in developing department fire
safety procedures.
E. Individual staff members are responsible for learning and following the clinic-wide and
departmental fire plans. Individual staff members are also responsible for learning and
using emergency reporting procedures for fires and fire hazards.
VI
PROCESSES OF THE FIRE SAFETY MANAGEMENT PLAN
The Organization manages fire safety risks (EC.5.10) Fire Safety Management Plan
(EC.5.10.1)
1. <your chc> 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
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Protecting Patients Staff and Others (EC.5.10.2)
The Director of Facilities or <designee> is 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.
1. The first is design of buildings and spaces to assure compliance with current local, state,
and national building and fire codes. <your chc> 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 vigorous construction monitoring and building commissioning program round out the
design phase.
2. The second phase is maintenance of the current building. Director of Facilities or
<designee> 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 <your chc> staff and contractors to ensure the end product of all
work maintains or improves the level of life safety in each affected area.
3. The third phase is an active program of fire prevention, fire safety, and fire response
training. The Director of Facilities or <designee> manages this phase of the program.
Fire Detection and Response System Tests and Inspections (EC.5.10.3)
The Director of Facilities or <designee> is responsible for maintenance of the Fire
Detection and Response Systems, including:
 All valve tamper switches and water flow devices
 All supervisory signal devices (except valve tamper switches)
 All duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm
boxes, and smoke detectors
 Occupant alarm notification devices, including all audible devices, speakers, and visible
devices,
 Off-premises emergency forces notification transmission equipment
 Fire pumps
 Water storage tank high- and low-water level alarms.
 Water storage tank low-water temperature alarms (during cold weather only)are tested at
least monthly.
 Main drain tests
 Fire department connections
 Fire pumps
 Kitchen automatic fire-extinguishing systems
 Carbon dioxide and other gaseous automatic fire-extinguishing systems
 Portable fire extinguishers
 Standpipe occupant hoses
 Standpipe systems
 Horizontal and vertical sliding and rolling fire doors
 Automatic smoke-detection shutdown devices for air-handling equipment
 Fire and smoke dampers
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Fire Response Plan (EC.5.10.4)
The 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.
The 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 Fire Safety Program
emergency procedures annually.
Fire Plan Elements
The roles of all employees, medical staff, volunteers and students at and near the point of fire
origin are defined. The basic plan in the clinic is based on the acronym
"RACE":
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Rescue anyone directly affected by the fire
Alarm by pulling fire alarm pull stations, and calling 911 on the phones
Contain or Close Doors to contain smoke and the products of combustion
Extinguish, and as needed prepare to relocate patients
The roles of all employees, medical staff, volunteers and students away from the point of fire
origin are to close doors, and evaluate the situation. If the fire is in horizontally adjacent
areas, or areas that are planned to relocate to the area, personnel should focus on where
transferred patients would be placed. In other zones, the plans should be reviewed, fire
response equipment discussed and checked, the oxygen valves checked for access, and the
responsibility for shutting off discussed.
The roles of others, such as students, physicians and other volunteers vary depending on the
situation.
Long term students or Americorps (90+ days) are generally trained as the staff are trained,
and monitored in their performance by supervisors or area staff
Short term students, most volunteers, and other visitors are requested to go into exam rooms,
and stay until the drill or emergency is over.

Physicians and other staff because they are not always available are asked to:
[1] If with patients, continue to work with the patient. Close the door if practical, but if not,
staff will close the doors
[2] If in another area, such as their office, cafeteria, etc. Stay there until the drill or
emergency is over and 'All Clear' is paged
[3] If in the hall or corridor, go to the nearest patient unit without going thru smoke or
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fire doors, and check in, to be available for any medical emergencies that may
occur.
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If a relocation or evacuation is deemed necessary, staff should
[1] Assure patients in the most affected areas are moved first, to adjacent zones.
[2] Patients are moved using the equipment and techniques usually used. Where
practical, ambulatory patients walk, or are move on wheel chairs. Non-ambulatory
patients are moved on wheelchairs or gurneys, as appropriate to their condition.
[3] Patients are moved into rooms in adjacent zones to protect them from the smoke and
product of combustion that may be in the corridor.
[4] If patients must be moved vertically, elevators provided with emergency power, and
with the permission of the Fire Department, are use to move patients to ground floors.
[5] If an evacuation is deemed necessary, the Incident Command Center is activated,
and the Evacuation Emergency plans activated.
Processes to Control Flammability of New Acquisitions (EC.5.10.5)
The Director of Facilities or <designee> and the Purchasing coordinator or <designee> are
responsible for managing the program to define the code requirements that furniture and
furnishings, including window draperies, and other curtains, furnishings, decorations are
expected to meet prior to purchase. <your chc> has written product specifications that are
detailed in the Acquisition of Interior Finish Products policy.
The Director of Facilities or <designee> is responsible for assuring fire rated products
installed during construction projects meet the standards. Fire-rated products are identified
for each project using standard specifications. The Director of Facilities or <designee>
maintains documentation on products installed during each project.
The Purchasing coordinator or <designee> is responsible for purchasing only fire /
flammability-rated replacement products meeting the standards defined. Department heads
that need to purchase products coordinate product evaluations with the Purchasing
coordinator or <designee>.
Life Safety Code®NFPA 101, 2000 edition (EC.5.20)
The Director of Facilities or <designee> is responsible for managing the program for
complying with codes and standards.
<your chc> 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. Where 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.
As issues are corrected, they will be closed in the Plan for Improvement. On a quarterly
basis, the SOC will be reviewed and any open items reviewed to determine their status. If
they 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 Director of Facilities or <designee> , and the Safety Officer,
and reviewed by the Safety Committee.
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The Director of Facilities or <designee> is responsible for the Statement of Conditions
document. The Plan for Improvement is reviewed quarterly to ensure work is progressing.
The Plan for Improvement is used to develop the operational budgets. Items over five
hundred dollars are included in the capital equipment budget. Items less than five hundred
dollars are included in the maintenance repair budget.
Fire drills (EC.5.30)
Fire 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 healthcare facilities on each occupied shift each quarter, and
evaluated on a randomly selected basis to assure that all elements of the drill activity are
exercised in all occupied areas during each alarm activation not announced as a bell test.
Fire drills are conducted in all other areas in which patient care takes place at least once a
year, with full evacuation of the affected area during the drill. These drills are witnessed and
documented, and evaluated to identify improvements that may be made. Additional drills are
held as deemed appropriate.
Fire drills will normally be unannounced, with the exception of those done as corrective
training activities.
All staff in the affected areas are required to participate in the drills to the extent the fire plan
describes. This includes all clinic staff, and all business tenants of <your chc>
Fire 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.
The 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. Staff knowledge and
response to drills is evaluated by a data collection document that includes:
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How, and under what conditions they activate the fire alarm, or call a Code Red
When it would be necessary to call 911 to alert the Fire Department
Their containment of fire and smoke, where appropriate
How they would move patients to areas of refuge (adjacent fire zones)
How they would use fire extinguishers, and when
Specific duties such as shut-off of oxygen valves, movement of medical records and
other emergency responses
What they would do if a building evacuation was announced.
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Maintaining fire-safety equipment and building features (EC.5.40)
Fire Alarm and Related Systems
The Director of Facilities or <designee> is responsible for maintenance of the fire alarm and
related systems. The activity of the Facilities Department is limited troubleshooting fire alarm
malfunction. Corrective and preventive maintenance to the fire alarm is performed by <fire
alarm vendor>, <fire alarm vendor> conducts the scheduled maintenance of all components
of the fire alarm. <fire alarm vendor> documents their work with forms developed by the
contractor and clinic-generated work orders.
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Supervisory signal devices are tested quarterly as part of Fire Alarm and Fire Pump
testing, by <your chc> staff.
Valve tamper switches and water flow devices are tested semiannually in conjunction
with sprinkler system testing, done by a contractor.;
Duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm
boxes, and smoke detectors are tested at least annually by a contractor, as part of
ongoing fire alarm system maintenance.
Occupant alarm notification devices, including audible devices, speakers, and visible
devices, are tested annually by a contractor, as part of ongoing fire alarm system testing,
and verified by staff by exception, during fire drills.
Off-premises emergency forces notification transmission test is done quarterly. This is
done automatically with activation of the Fire Alarm system, and verified quarterly by the
vendor.
Each fire pump is tested at least weekly under no flow condition to verify operations, water
bearing activity, and timeout operations.
Each water storage tank high- and low-water level alarms is tested at least
semiannually
Each water storage tank low-water temperature alarms is tested at least monthly during
freezing weather periods
Main drain tests are conducted at least annually at all fire alarm system risers by a contractor.
Each fire department connection is inspected quarterly by Engineering staff, as part of
equipment rounds. Problems are documented by exception.
Each fire pump is tested at least annually under full flow, by a contractor, in conjunction
with Fire Insurance and Fire Department staff. Flow curves are calculated and compared
with normal flow to test the pump's continuing function.
Carbon dioxide and other gaseous automatic fire-extinguishing systems are tested for
proper operation at least annually by a licensed contractor.
Each portable fire extinguisher is clearly identified, inspected at least monthly, and
maintained at least annually by a licensed contractor. In addition extinguisher access is
evaluated during ongoing environmental tours.
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Standpipe occupant hoses are hydrostatically tested five years after installation and at least
every three years thereafter; where installed, and the standpipe systems receive water-flow
tests at least every five years as part of the fire pump testing.
Each fire and smoke damper is operated at least every four years (with fusible links removed
where applicable) to verify that they fully close, where such dampers may be reached.
Dampers installed in building locations which are inaccessible are maintained on the SOC
and replaced by assessable dampers when renovations are done in the affected areas.
Each automatic smoke-detection shutdown device connected to air-handling
equipment is tested (operationally activated) at least annually.
Each horizontal and vertical sliding or rolling fire door is tested for proper operation and full
closure at least annually during ongoing maintenance activity.
Activity of the <your chc> facilities staff is generally limited to troubleshooting and minor
repair. Competent contractors are used to test, inspect, maintain and repair systems where
needed, to assure the special skills and equipment they have are available. Documentation is
maintained as part of the <your chc> database, to assure testing is done in a timely fashion,
and to document results.
Interim Life Safety Measures (ILSM) (EC.5.50)
The Director of Facilities or <designee> is 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.
An assessment tool is used to evaluate each situation to determine if the degree of deficiency
warrants ILSM and what specific measures are required to minimize the effects of the
deficiency. This is also part of the preconstruction risk assessment process.
The assessment evaluates the risk of non-compliance with each of the elements of the Unit
Concept of the Life Safety Code (i.e., smoke and fire walls, floor separation, exiting, building
construction, fire alarm system activity). Where any construction or identified deficiency is
identified, the 11 key elements of the ILSM are evaluated, and where applicable to the
deficiency or construction activity, compensatory activity is implemented.
The Director of Facilities or <designee> is responsible for communicating the findings to
appropriate managers, staff, contractors, and senior leaders. In addition, the Director is
responsible for monitoring implementation of the ILSM and taking action when they are not
being observed.
The schedule of monitoring and documentation is determined on a per project basis. The
Director of Facilities or <designee> is responsible for maintaining all ILSM documentation
from the onset through elimination of the deficiencies. Regular reports of ILSM programs will
be made to the Safety Committee.
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Reporting and Evaluation of Incidents (EC.9.10.1)
<your chc> assigns responsibility to individuals to monitor and report to the Safety Committee
on a quarterly basis the following:
RESPONSIBILITY
Patient, visitor, and property incidents
Occupational illnesses and injuries to staff, OSHA
log, and worker's compensation
Security incidents
Hazardous materials and waste incidents
Fire and life safety management issues
Medical equipment problems, failures, and user
errors
Utility management problems, failures, and user
errors
Radiation Safety incidents
General safety incidents
ASSIGNED INDIVIDUAL
<Risk management or designee>
<Human resources or designee>
<Security team leader or designee>
Facilities or designee
Facilities
Facilitatesor designee
Facilities or designee
Facilities or designee
Facilities or designee
Safety
Committee
chair or designee
Radiation
Safety Officer
Monitoring and Response to Conditions in the Environment (EC.9.10.2)
The Safety Officer coordinates the collection of information about deficiencies, problems,
failures, user errors, and opportunities for improvement in the environment of care. This
occurs through reports to the Safety Committee from the seven environment of care areas.
The information is collected to evaluate the effectiveness of programs and improve
performance.
The Safety Officer is responsible for providing quarterly reports to the Safety Committee on
hazard surveillance, risk assessments, product recalls and hazard notices, policy and
procedure review status, and other environmental risks and safety issues.
The Safety Officer coordinates semi-annual and annual hazard surveillance, participates in
monthly hazards surveillance rounds, and participates in development of environmental
safety policies and procedures.
Ongoing Monitoring of Actual or Potential Risks (EC.9.10.3)
The Safety Officer coordinates the performance measurement and improvement process for
the environment of care areas. These measurements are reported to the Safety Committee
on a quarterly basis for review and action if necessary. Each EC area is required to monitor
at least one performance improvement indicator annually.
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Annual Evaluation of EC Management Plans and the Scope, Objectives,
Performance, and Effectiveness of the EC Management Programs (EC.9.10.4 to
EC.9.10.5)
The Safety Officer coordinates an annual evaluation of the objectives, scope, performance,
and effectiveness of each of the seven EOC management plans. This is reported to the
Safety Committee and to the Board of Directors.
This includes a variety of information sources including Safety Committee reports and
minutes, incidents reports, and staff knowledge surveys.
The review of the scope of the plan based upon changes to the Joint Commission
Environment of Care Standards, changes to other applicable standards, and changes to the
physical structure, equipment, and external influences. Goals and objectives are evaluated by
the degree to which they are achieved. Performance is evaluated by data related to required
activities and improvement measures. The effectiveness of each activity is assessed by
whether the management plan achieved the intent, and is ranked as yes, substantial, or no. If
the effectiveness is no or substantial, a goal for improvement for the following year to improve
effectiveness is established. Management plans are updated to address identified changes or
needs.
Integration of the Environmental Monitoring and Response into the Patient
Safety Program (EC.9.10.9)
The Safety Officer and Risk Manager are members of the Patient Safety Team and coordinate
the integration of patient safety and environmental issues. This includes information from team
meetings and data, incident reports, patient safety rounds, hazard surveillance rounds, and
other information.
Safety Committee (EC.9.20.1)
The Safety Committee is multi-disciplinary including clinical, support, and administrative
representation. The committee considers and evaluates reports, and approves actions
to address identified environment of care issues at regularly scheduled meetings.
Safety Committee Meetings (EC.9.20.2)
The Safety Committee meets at least ten times per year.
Environment of Care Information (EC.9.20.3)
Managers of each EC function and the Safety Committee collaborate to analyze EC issues.
The analysis includes ongoing evaluation of performance and aggregate analysis of
environmental tours, incident reports, maintenance activities, and other issues.
The analysis is used to manage the stability of current programs, assess risks related to new
programs, and to identify opportunities for improvement.
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Reporting of Environment of Care Activities (EC.9.20.4)
The Safety Committee publishes minutes of each meeting. The minutes summarize materials
presented, issues identified, and actions to be taken.
Establishing Measurement Guidelines (EC.9.20.5)
Managers of each EC function are responsible for identifying important measures of the
safety program. The measures are used to evaluate performance on an ongoing basis, to
measure the success of implementation of performance improvement activities and to
develop an understanding of processes that are not meeting expectations.
Communication with Leadership (EC.9.20.6)
Minutes and relevant supporting materials are communicated to all EC and organization
leaders. All managers are required to read the materials and respond as appropriate.
Identification of Performance Improvement Opportunities (EC.9.20.8)
When EC managers and the EC Committee identify performance improvement opportunities,
a proposal for improvement is prepared and sent to leadership. The leadership reviews all
improvement proposals and determines the priority and need for the proposed improvement.
When leadership approves a proposal, appropriate staff or a team is appointed to address
the identified issues and to design a process improvement. The staffer team appointed make
regular reports to the EC Committee and leadership. The reports address progress toward
improvement, including measurement of changes to assure they are effective and
sustainable.
Communication between Environment of Care and Patient Safety Leadership
(EC.9.20.9)
The minutes of the EC Committee are sent to the Patient Safety Committee. Issues of interest
to the Patient Safety Committee are presented for discussion and action as appropriate. The
minutes of and issues identified by the Patient Safety Committee are handled in the same
manner before the EC Committee.
Orientation, Training, and Education (HR.2.10-HR.2.20)
All staff must attend new employee orientation with one session on the first day of work and a
second session within the first month of employment. New employee orientation addresses
key issues and objectives of all seven areas of-the EC including the role each area and staff
play in the overall safety program, OSHA Right to Know, blood borne pathogens
requirements, and incident reporting.
Employees also receive departmental safety orientation at their respective work areas
regarding hazards and their responsibilities to patients, visitors and co-workers.
Continuing education for safety is dependent upon the departments with their respective
identified needs.
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An annual safety educational event is developed based on Safety Committee topic
recommendations with mandatory attendance for all employees.
Monthly safety tips are developed and distributed to all departments and are available on the
intranet.
Specific staff education programs are developed and monitored within the seven EOC plans
in consultation with representatives from the Safety Education committee.
Related policies'.
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Safety/Environment of Care Education (Safety)
Approved by Safety Committee
Approved by the Board of Directors
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