We recently surveyed our customers and email subscribers about safety during hospital renovation and maintenance projects. Our survey asked respondents to describe which safety issues they feel are most commonly overlooked before and directly after a project starts; which safety concerns keep them up at night - and for one pressing question they'd like to ask an industry expert. We took the most asked fire safety questions to our advisor and self proclaimed Fire Geek, Joshua Brackett (PE, SASHE, CHFM). We also asked Josh about the fire safety questions and challenges he most often encounters.
Josh is a licensed Fire Protection Engineer (PE), Senior Status as ASHE (SASHE) and Certified Healthcare Facility Manager (CHFM). As Life Safety Special Projects Manager at Baptist Health in Little Rock, Arkansas, Josh oversees Joint Commission compliance, energy management, construction policies and procedures and department process improvement. As Co-founder and Chief Learning Officer at Legacy FM, Josh serves as SME developing healthcare facilities management training and empowerment programs.
Table of Contents
- Responsibility for adherence to fire codes and standards requirements
- Top fire safety challenge Josh encounters
- How to determine when a 1 hour fire rated barrier is required
- How to know which fire codes to look for and follow
- How regional fire codes differ
We kicked off our conversation with Josh by asking about one of the topics that came up a lot in our survey responses:
1. Who is responsible for adherence to fire code requirements?
“Individual inspecting, testing and maintenance (ITM) activities can technically be assigned to contractors or facilities team members, but the ultimate responsibility lies with the Facilities Manager,” Josh answered. Why? “If something goes wrong and the Joint Commission, State Inspector or Fire Marshal investigates, it’s up to the FM to know and explain every detail: from what failed/broke to a list of Interim Life Safety Measures (ILSM) enacted as well as proof of repair, retesting and passing.”
The proactive step here is implementing a strong ITM, ILSM, and repair/retest/recertify process. “Having a solid process and training others on how to use it and enforcing consistency will help explain failures during surveys,” Josh explained.
2. We then asked Josh to describe the fire safety question or challenge he encounters most frequently.
“Hands down it’s an overall lack of understanding of the requirements during occupied renovations by everyone involved (architects, contractors, FMs, engineers, etc)”Two common examples of this challenge:
- The difference between renovation, modifications or change of use - and what you need to do and which codes to follow for each. Josh recommends referencing the National Fire Protection Association (NFPA) 101 (2012) Chapter 43 for more information on these terms and when they apply. We’ll dive further into NFPA codes later in this blog post.
- Requirements for fire rated barriers: Josh says awareness on this varies pretty drastically throughout the industry, particularly for above ceiling components. “This is at least partly due to fire rated barrier guidelines being somewhat newly enforced,” he explained. “The requirements for construction in the means of egress in any ongoing healthcare construction compliance have been around for a long time, but not many AHJs or surveyors knew about it or were enforcing it.” He also mentioned fire rated barrier requirements become more important and recognized with larger projects.
Josh’s advice for solving this challenge is one he came back to frequently throughout our discussion: getting everyone involved on the same page about project specific requirements as early as possible.
3. Speaking of 1 hour fire rated construction barriers - this was a hot topic in our survey. How do you determine when one is required?
“Start with NFPA 101 (2012), Chapters 18 and 19,” Josh recommends. These chapters dictate the means of egress in any area undergoing construction shall comply with NFPA 241 (2009). NFPA 241, which is the Standard for Safeguarding Construction, Alterations and Demolition Operations, requires 1-hr rated separation between occupied and construction spaces or NFPA 13 compliant sprinkler protection.
It’s also important to remember walls are treated and listed as an assembly, and to reference the listing requirements to ensure the wall is constructed appropriately. For example: UL 263 or ASTM E119 address testing methods for evaluating fire resistance ratings of these barriers and there are many listed assembly options, so look for the mark bearing adherence to this criteria. Note: These standards are sometimes confused with UL 723 and ASTM E84, which provide the testing criteria for the surface burning characteristics (flame spread index and smoke developed index) of materials. This is also important as healthcare occupancies are limited on the classification of surface materials that can be installed. Stay tuned for more on ASTM E119 and ASTM E84.
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4. Now for a big one: how do FMs & PMs know what to look for and what to follow for fire codes?
Josh was not surprised this was one of the top concerns collected in our survey. He recognizes it's a significant challenge - and provided great guidance: “Start with determining what is required and then dig into how to implement the requirements.”
The two main sources for what is required for hospitals by The Centers for Medicare & Medicaid (CMS) are:
- National Fire Protection Association (NFPA) 101 (2012) The Life Safety Code
- NFPA 99 (2012) The Healthcare Facilities Code
- NFPA 80: Fire doors and other opening protectives
- NFPA 72 Fire alarms
- NFPA 13 & 25 Sprinkler installation & ITM
- NFPA 110 Generators/emergency power systems. A hospital requirement
- NFPA 70 National Electrical Code. Technically a mix of what and how
“Keep in mind there may be additional codes required for your state or local jurisdiction,” Josh advised.
5. How do regional fire codes differ?
“I am asked about this all of the time,” Josh said. And the answer is complicated. The driving factor in the complication is that codes adopted by state and local fire marshals differ from those adopted by Centers for Medicare & Medicaid Services (CMS).
Josh broke down the complication for us:
- Many states and local fire marshals adopt the building codes - usually either International Building Code (IBC) or state specific iterations.
- Meanwhile, the CMS adopted NFPA 101 (2012) and NFPA 99 (2012) as part of Federal Law in a portion known as the Condition of Participations (CoP) for Hospitals.
- And, there are some conflicts between NFPA and IBC codes.
- The result? Typically, the most stringent set - and often a combination of codes - are chosen for a project to limit liability.
Here’s a scenario of how this plays out:
- NFPA 90A states a fire damper is only needed when exiting out of a 2-hr rated shaft.
- IBC requires a combination fire/smoke damper.
- If both codes are set for the project and the engineer is choosing the most stringent, they often represent the need for a combination fire/smoke damper.
- This suddenly transforms from a simple mechanical fire damper to a damper that requires mechanical, electrical and fire alarm inputs and coordination - which increases the time and cost of the project.
Josh's mitigation advice here is one that rings true across many fire safety and other healthcare project challenges: “Get everyone (architect, engineers, contractors, FMs) on the same page regarding which codes are required for a specific jurisdiction before a project begins. This will go a long way in reducing time and costs by limiting RFIs and clarifications and/or change orders.”
To find current code/standards adoptions, Josh recommends the following resources - each include maps.
- ICC's International Code Adoptions
- NFPA's Code Finder
- NPFA's NEC Enforcement & Map
- FGI's Guidelines & State Adoptions
There are also a few third-party companies that work to keep up with an updated list, such as UpCodes.
Note: These websites should always be used with discretion. Always visit state or local jurisdiction's website or call to verify the applicable codes. Most states and local jurisdictions have the current codes listed on their website.
For specific code conflict concerns, Josh recommends reaching out to local/state AHJ and/or using membership forums, such as MyASHE for Healthcare FMs to ask how others are handling the conflict.
Stay tuned for more fire safety advice from Josh!
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