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RTN1405_B7_Top 5 Hot Buttons @ EC

* EC:The Top Five Hot Button Issues in EC: Joint Commission Life Safety Code ® Surveyors name the most common compliance problems[®] [REF: EOC, SFT] EC News, May 2014, Vol 17, #5, Pg 5JCe1405_B7

In this piece, the authors describe “five common problem areas in hospitals” based on 2013 survey experience. Brief compliance suggestions are provided. The 5 (along with suggested compliance references) are:

1 Corridor Clutter: Take advantage of dead-end spaces that do not exceed 50 sq ft.
—Ref: LSC Handbook, 2000, Section 18.2 Means of Egress Requirements
2 Penetrations: Develop a quality barrier management program (see C&E: Managing Barrier Integrity, EC News 7/12)
—Ref: LSC Handbook, 2000, Section 8.3 Smoke Barriers
3 Door-related Issues:
—Ref: Fire-Rated Doors and Hardware: A Guide to Field Inspection
—Ref: NFPA 80: Standard for Fire Doors and Other Opening Protectives
4 Ventilation:
—Ref: 2010 FGI Guidelines for VentilationLook for the free read only copy link near bottom of page.
5 Fire Alarm-Related Documentation
—Ref: NFPA 72: National Fire Alarm and Signaling Code

Tip: For additional details/background on the above, go to the comments section of this article and also review the SPHCC Custom Information Feed of the Clarification & Expectations Series (CIF_EC-C&E)


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One response to “RTN1405_B7_Top 5 Hot Buttons @ EC”

  1. • PR: – Clarifications and Expectations: Managing Barrier Integrity [REF: EOC, LDR, SFT]
    Perspectives June 2012, Pg 3, Vol 32, # 6
    Clarifications and Expectations is a relatively new column featuring practical explications of Life Safety
    Code by George Mills, MBA, FASHE, CEM, CHFM, CHSP, Director, Department of Engineering, The Joint
    Commission. The focus for this month is fire and smoke barriers. Hospitals are designed with wall-to-wall
    and floor-to-ceiling smoke and fire barriers that allow for containment of fires/smoke for critical periods of
    time and faster/more convenient lateral evacuation (when necessary) of patients (i.e., defending in place)
    instead of having to completely leave a building. However, defending in place is critically dependent on
    properly protecting openings in those barriers such as doors (e.g., fire-barrier doors that must be selfclosing
    and latching vs. fire-barrier doors that are similar, but do not have to be latching) and penetrations.
    Last year TJC surveys frequently included citation of penetrations (especially above the ceiling) fire
    barriers (LS.02.01.10 52% of surveys) and in smoke barriers (LS.02.01.30 45% of surveys). These same
    standards were cited in more than a third of SPHCC member surveys as well. In addition to providing
    excellent definitions of the key terms and requirements, the article and Mr. Mills recommend a strategy of
    limiting access to fire/smoke barriers by implementing a Barrier Access Program. The essence of the
    program is that anyone working above the ceiling must have a formally issued, time and date-limited,
    Barrier Access Permit prominently displayed on their ladder. In addition, all staff are trained and
    encouraged to report (not challenge) any ladder observed without that permit to security. The reporter is
    rewarded through the paying of a bounty (e.g., gift card). Other tips for better protection and management
    of barriers included conducting annual and random barrier/penetration inspections and using the same
    manufacturer of approved fire-stop rated products (vs. polyurethane expanding foam that is a good
    insulator, but burns rapidly and emits toxic smoke). Note also that penetrations can be listed in batch
    mode as a single PFI on the SOC if they are accompanied by a specific list or drawing identifying specific
    penetration locations
    • PR: – Clarifications and Expectations: Managing Door Maintenance [REF: EOC, EM, LS]
    Perspectives April 2012, Pg 6, Vol 32, # 5
    Clarifications and Expectations is a new series authored by George Mills. It will focus on
    compliance issues related to Life Safety and EOC. This first offering focuses on the
    maintenance of doors in general and the failure to latch by doors that are required to do so.
    TIP: Whether as a stand-alone or part of an existing safety rounding process or fire drill
    critique (as required by EC.02.03.03, EP 5), consider the use of a door inspection checklist.
    [PEARL] A sample door inspection checklist is included on page 7. Given the large number
    of doors in any facility, the inspection process might seem daunting. To keep it from being overwhelming, the article suggests categorizing the inventory of your doors (e.g., fire doors,
    smoke doors, corridor doors, etc.), then inspecting them at different rates based upon factors
    such as the frequency of traffic through the door or its relative importance to fire safety risk


    See the article “Ensuring Full
    Compliance with the Life Safety Code”
    (EC News, July 2013, pages 5, 6, 9) at
    /art00003/ for more information.

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