Fire safety is a highly complex and vital component of healthcare facility safety management requiring comprehensive staff training, preventative maintenance, and emergency planning. Automatic sprinkler systems offer the best protection against fire however this does not absolve healthcare organizations from their duty to have fire safety programs in place (FM Global, 2022). HIROC claims have demonstrated that fires can result in significant injuries and property loss. Even a small, contained fire has the potential to cause injury or extensive property damage.
Implement standardized evidence-based fire prevention and property loss control inspection protocols, including (but not limited to):
o Hot work protocol;
o Code and occupant compliant fire safety inspection process;
o Employee-owned electrical equipment and appliances in the workplace policy.
Implement a formal contract (e.g., commercial lease agreements and rental agreements) and contractor management strategy.
Ensure the complete and timely documentation and communication to management of all:
o Scheduled and ad hoc fires safety inspection and related deficiencies;
o Corrective / remediation steps implemented;
o Rationale / justification for not implementing corrective steps.
Additional Considerations
- Examples of elements to consider in the contractor management strategy:
- Contractor selection and review;
- Contractor supervision (site access and identification);
- Hot work management;
- Fire protection impairments;
- Reporting of incidents and property damage;
- Smoking regulation;
- Access to utility areas;
- Housekeeping requirements and trash removal;
- Hazardous material storage, use, and disposal requirements;
- Management of emergencies (FM Global, 2007) (FM Global, 2020).
Additional Considerations
- Examples of elements to consider in the hot work protocol and / or program:
- Determine if hot work is necessary or if alternative mechanical means can be used;
- Prohibit hot work in areas where it cannot be safely conducted;
- Assign a designated individual to oversee hot work operations;
- Examine the hot work area, and complete (with the contractor present) and display a hot work permit (e.g., FM Global Hot Work Permit) in temporary and designated hot work sites;
- Follow all applicable precautions listed on the FM Global Hot Work Permit and apply all that are applicable to the occupancy;
- Remove any flammable liquids (paints, oils, and lacquers) and combustible materials from the hot work area where possible. Otherwise, protect with FM approved welding pads, blankets and curtains, fire-resistive tarpaulins, or metal shields;
- Ensure fire protection systems remain in service during any hot work operation;
- Implement ‘fire watch’ during and after the hot work for the required duration;
- Obtain the contractor’s signoff on the permit after the completion of the hot work;
- Conduct a final inspection of area and confirming the area is fire-safe;
- Retention and storage requirements for hot work permits (FM Global, 2018) (FM Global, 2021b) (FM Global, 2013).
Additional Considerations
- Examples of elements to consider in inspection of fire protection equipment:
- Weekly - visual inspection of each sprinkler control valve for accessibility and to ensure it is locked in the open position;
- Monthly - physically turning all non-indicating valves five to seven turns closed, then re-opened and locked;
- Quarterly - test all sprinkler water flow alarms for operations and alarm indication;
- Annually - flow main drain at each riser and test dry-pipe, preaction and antifreeze loop systems(FM Global, 2020) (FM Global, 2022) (FM Global, 2016) (FM Global, 2018).
- Examples of elements to consider in inspection of fire pumps:
- Weekly – visual inspection of each fire pump for access and condition; perform pressure drop tests accordance with codes requirements;
- Annually - conduct full-performance flow test on all fire pumps and underground water mains. Also perform a check of the alignment of the coupling (FM Global, 2020) (FM Global, 2018) (FM Global, 2021a).
- Examples of elements to consider in inspection of facility maintenance / housekeeping:
- Monitor general order and neatness, trash removal and unnecessary combustible material especially in high-value areas such as laboratories, computer room, etc. Maintain a minimum of 36 inches of clearance between combustible material and electrical equipment;
- Monitor of electrical, mechanical, boiler and telephone rooms (cool, clean, dry, and free of any combustible storage);
- Ensure storage areas are well arranged and neat. Observe aisle spacing between storage. Confirm sprinkler heads are unobstructed, with a minimum of 18 inches of clearance;
- Survey secured areas, access openings, and locks for intrusion damage;
- Inspection of smoking regulation violations in hidden areas, stairwells, and restrooms (FM Global, 2018).
Additional Considerations
- Example of elements to consider within the employee-owned electrical equipment and appliances in the workplace policy:
- Approval process to use employee / independent contractor owned or leased electrical equipment / appliances in the workplace (City of Toronto, 2015);
- Inspection requirements (when required);
- Safety standards and requirements (City of Toronto, 2015);
- Employee’s / independent contractor's responsibilities;
- Types of equipment/appliances not permitted.
