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
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   • 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
   reduction.

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   See the article “Ensuring Full
   Compliance with the Life Safety Code”
   (EC News, July 2013, pages 5, 6, 9) at
   http://www.ingentaconnect.com/content
   /jcaho/ecn/2013/00000016/00000007
   /art00003/ for more information.

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