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How to Create a Concise Life Safety Plan?    05/18/17

You are the Facility Manager of a Hospital and are only months away from a CMS or Joint Commission survey. Typically, one of your many goals during this hurried time is to have your Life Safety Plans updated. First you must find them and then you must determine if they are accurate. Since your last survey your facility has likely undergone one or more renovations, or possibly an addition. Generally, you don’t have a singular set of documents that accurately depict your current plans or that represent your Life Safety Strategies. The above situation is all too common and will generally produce less than desirable results.

In addition to their sometimes-hasty creation or revision, Life Safety Plans are most often bi-products of construction documents. Construction documents are primarily focused on construction efforts and communicate where various smoke and/or fire ratings should be, but don’t always communicate why they are there. An example of this is the use of a 2-hour fire barrier within a healthcare facility. The construction documents will show the extents of where these walls are and even describe various ways of constructing them, but in some instances, poorly define whether the barrier represents an Occupancy Separation, a Construction Type Compartmentation, or a Horizontal exit.

Hospitals are unique in the way in which they operate from a Life Safety standpoint, having the “Defend in Place” mindset. As important as it is to have the facility built properly, it is equally important that the staff and the facility function well together and that the facility is maintained properly. Clear and concise Life Safety Plans are the best way to achieve this.

Successful Life Safety Plans should be the basis which staff manage their “defend in place” strategies from, as well as, maintain them. The best Life Safety Plans are graphic depictions of the facility’s Life Safety Strategy along with other considerations. Below is a partial list of items that should be clearly depicted on these plans:

  • Building Separations
  • Occupancy Types
    • Occupancy Separation
    • Integration
  • Minimum Construction Requirements
    • Construction Types
    • Type Compartmentation
    • Year Constructed
  • Means of Egress Components
    • Exit Discharge
    • Corridors & spaces open on to them
    • Stairs
    • Areas of Refuge
    • Smokeproof Enclosures
    • Elevators
  • Suite Types & Square Footages
    • Sleeping
    • Patient Care Non-Sleeping
    • Non-Patient Care
    • Hazardous
  • Hazardous Area Protection
  • Travel Distances
    • Suite
    • Smoke
    • Exit
    • Common Path of Travel
  • Protection of Vertical Openings
    • Egress
    • Mechanical
    • Chutes

What do your healthcare facility’s life safety plans look like? Are they good graphic depictions of your strategy?