University of Kentucky Hospital

Fire Safety Management Plan

 

 

 

Scope and Program Coordination

 

The Fire Safety Management Plan defines processes through which the University of Kentucky Hospital provides a fire-safe environment for patients, visitors, staff, and protects Hospital property from fire and smoke damage. This plan covers all Hospital facilities and occupancies located on the Medical Center Campus and Kentucky Clinic North.

 

Coordination of the Fire Safety Management Program is a shared responsibility of the Hospital Safety Officer, Medical Center Physical Plant Division, and the University of Kentucky Fire Marshal. All Hospital employees participate in the Fire Safety Management Program.

 

University of Kentucky Hospital has established programs and practices, including

• a Building Maintenance Program

• an Interim Life Safety Management Program

• a Statement of Conditions (SOC) coordination program

and

• a facility fire plan

to maintain the facilities in compliance with the Life Safety Code (LSC) and to comply with National Fire Protection Association (NFPA) standards. In compliance with JCAHO, the Hospital has adopted LSC NFPA 101 2000 as its standard, except when KY Building Code or other state and local requirements are more stringent. The University of Kentucky fire marshal evaluates all proposed changes to facility life safety features and is involved in the planning of all construction and renovation projects. (Note: The Interim Life Safety Program is outlined in a separate document.) The state fire marshal or his/her designee reviews and inspects all changes to the facility that affect life safety.

 

Objectives

 

The processes included in the Fire Safety Management Plan are designed to meet specific objectives.

 

·         Ensure proper operation of fire detection, alarm, and suppression systems through a program of inspection, testing, and maintenance.

·         Ensure proper maintenance of other built and installed life safety features, such as fire and smoke walls, and fire doors.

·         Provide and maintain portable fire extinguishers according to established criteria for type, placement, inspection, maintenance, and use.

·         Ensure that acquisitions such as curtains, furniture, waste baskets, bedding, and other equipment meet established fire safety criteria.

·         Investigate and recommend actions to correct deficiencies, failures, and user errors that may impact fire prevention or safety. 

·         Ensure that all employees and others working within the building understand the building’s life safety features and their roles in fire prevention and response. 

·         Ensure that fire response procedures address institutional and departmental/area needs. 

·         Establish processes for identifying deficiencies and collecting data regarding fire prevention and life safety processes and staff compliance.  

Fire Alarm Systems

 

The fire alarm system is inspected, tested, and maintained by Simplex/Grinnell through a service contract.  The established program includes, but is not limited to 1) quarterly testing of all circuits and 2) annual preventive maintenance of all components.

 

Fire Detection System

 

The Hospital has a fire detection system that minimizes smoke transmission by controlling designated fans and dampers in air-handling and smoke-management systems. All fire alarms are monitored by Simplex and transmitted to the local fire department. The alarms are also received in PPD dispatch and announced to the facility.

 

Simplex Grinnell maintains the fire detection system. The system is tested in accordance with NFPA 72 during regular quarterly inspections. The Hospital maintains a contract with Simplex.

 

Automatic Fire Extinguishing Systems

 

The Hospital maintains outside contracts for inspecting, testing, and maintaining the automatic fire extinguishing systems. The MCPPD Preventive Maintenance Manager oversees the program and maintains documentation.

 

Portable Fire Extinguishers

 

The University of Kentucky Fire Marshal’s Office provides portable fire extinguishers for University of Kentucky Hospital facilities.  The portable fire extinguisher program has been established in compliance with NFPA standards. Fire extinguishers within the Hospital are identified, placed, maintained, and used in compliance with these standards.

 

The UK Fire Marshal services all fire extinguishers annually. Hospital representatives inspect all fire extinguishers monthly.

 

System Monitoring and Transmission of Signal

 

Medical Center Physical Plant Dispatch monitors the fire alarm system for the purposes of identifying location of alarm, reset, and other internal functions.

 

The University of Kentucky has established a contract with Simplex-Grinnell to act as a central station to monitor and automatically transmit the fire alarm signal to the fire department.       

 

Built and Installed Life Safety Features

 

The Hospital’s built and installed life safety features, such as fire and smoke walls and fire doors are inspected and maintained by Medical Center Physical Plant as a part of the building maintenance program.

 

In addition, the safety surveillance team inspects such features as a part of the routine inspection of the Hospital and submits work orders to PPD for all deficiencies noted.

 

Medical Center Physical Plant maintains accurate drawings of fire and smoke compartments.

 

Flame Resistance Requirements for Room Furnishings and Other Items

 

All room furnishings used in the Hospital must meet certain flame-resistance standards. These standards, established by Life Safety Code, are detailed in the operating manuals of these departments or offices designated as ordering consultants.

The ordering consultants and process for reviewing proposed acquisitions is outlined in Hospital Policy 04-19.

 

Fire Drills

 

Fire drills, totaling at least 1 per shift per quarter, are conducted in all Hospital healthcare occupancies, according to an established schedule. All fire drills are unannounced. Only trained evaluators from each service area have access to the established schedule. Fire drills exercise all primary elements of the fire plan, including employee knowledge of:

 

§         Use and function of fire alarm systems

§         Transmission of alarms

§         Containment of smoke and fire

§         Transfer to area of refuge

§         Fire extinguishers and other life-safety features

§         Fire response duties

§         Extinguishing fires

§         Building evacuation

 

All fire drills are evaluated by trained monitors at the drill site, a smoke compartment on the same floor and adjacent to the drill site, and a smoke compartment either immediately above or below the drill site. Safety Training Coordinators or their designees evaluate other areas as deemed necessary by past performance or the need for performance improvement. 

 

Hospital-owned or –operated business occupancies conduct and evaluate fire drills at least annually.

 

Building Maintenance Program

 

The Hospital has an ongoing building maintenance program designed to resolve life safety code deficiencies as they are identified whenever possible, rather than creating projects for their long-term resolution.

 

The goal of the building maintenance program is to ensure that at least 95% of the life safety features function properly at all times. The inspection schedules for each life safety feature have been established based on historical maintenance data to help ensure at least 95% compliance rate for that item. The program’s effectiveness is evaluated by regular inspections and by monitoring the work order documentation.

 

The building maintenance program checklist includes, but is not limited to:

 

·         1 1/2-hour FRRA door and 1-hour FRRA doors (including occupancy separation doors, stair doors, horizontal exit doors, and hazardous area room doors)

·         positive latching

·         self-closing or automatic closing devices in proper working order

·         no more than 1/8 inch gap between edges of door pairs

·         no more than ¾ inch undercut

·         Linen and trash chute doors

·         Positive latching

·         Self-closing or automatic closing devices in proper working order

·         Smoke barrier doors

·         Self-closing or automatic closing devices in proper working order

·         Maintained to prevent spread of smoke

·         Corridor doors

·         Positive latching

·         Maintained to prevent spread of smoke

·         Smoke and fire walls

·         Free of penetrations

·         Properly sealed

·         Egress illumination devices functioning (battery operated only)

·         Exit signs lighted

·         Grease producing devices (exhaust hoods, exhaust duct system, grease removal devices)

·         Clean

·         Maintained according to schedule

 

The Hospital has an inclement weather plan that ensures that egress paths are free of ice and snow.

 

Reporting and Investigating Deficiencies, Failures, and User Errors

 

Medical Center Physical Plant (PPD) has an established reporting and work order system at allows users to report deficiencies, failures and other problems with the facility or its systems directly to Physical Plant. Dispatch personnel establish a work order for each report made, based on established criteria. Once a work order is generated, area mechanics and other specialized Physical Plant personnel are dispatched to investigate and reconcile, if possible, problems reported. PPD personnel are required to close a work order when investigation and reconciliation are complete. PPD Dispatch personnel send notice that the work order has been closed and how the problem was resolved to the individual who submitted the report.

 

Users can report problems by calling PPD Dispatch at 3-6281 or by sending an email to ppdmcwo@pop.uky.edu.

 

In addition, the Hospital has a multi-faceted risk assessment program, designed, in part to proactively evaluate the life safety features/systems of Hospital buildings.

 

That program includes, but is not limited to:

 

·         Regular inspections/surveillance

·         Random inspections/surveillance

·         Construction/renovation meetings and site inspections

·         Reportable occurrence reports

·         False fire alarm reports

·         Established periodic testing of mechanical life safety systems

·         Fire drills and evaluations

 

The Hospital Environment of Care Committee and its subcommittees are actively involved in evaluating safety trends and issues, recommending action, and monitoring implementation.

 

All hospital areas are evaluated on their compliance with life safety/fire prevention standards as a part of the semi-annual inspection. Each area is expected to score 95% or above on life safety standards. The results of the inspection are reported to the service director, manager, and administrator.

 

The fire department and designated Security and PPD employees respond to all fire alarms. Only the ranking fire department officer can authorize a system reset after the alarm is activated. The reset is authorized after the cause of the alarm is identified.

Fire Prevention/Life Safety Education and Training

 

The Hospital Safety Officer develops the safety curriculum for 1) Hospital orientation and other orientation programs for special audiences (i.e., residents, volunteers, teen volunteers, contractors),  2) supervisory training program, and 3) continuing education programs.

 

Based on JCAHO standards and identified institutional need, the safety officer has identified the following issues to be included in life safety/fire prevention orientation:

 

·         Roles and responsibilities of personnel at the fire’s point of origin

·         Roles and responsibilities of personnel away from the fire’s point of origin

·         Use and functioning of fire alarm systems

·         Roles and responsibilities in preparing for and executing building evacuation

·         Location and use of evacuation equipment

·         Building compartmentalization and procedures for containing smoke and fire

 

Employees who have specific fire response assignments are educated and trained as a part of their departmental orientation and continuing education.

 

Hospital employees are required to attend Hospital Orientation and must participate in departmental orientation and continuing safety education programs.

 

Educational materials and/or education/training sessions tailored to the needs of volunteers, physician staff, students, contract staff, and other personnel include information about fire prevention and life safety. The Hospital Safety Officer and others participate in the development, review, and evaluation of these materials.  

 

Staff knowledge of fire response procedures is evaluated by the following:

 

·         Annual safety survey—Hospital employees surveyed will be able to answer 95% of the fire prevention questions accurately. The survey is conducted by area Safety Training Coordinators.

·         Questions during Safety Surveillance—Hospital employees are questioned about fire response procedures and are rated on their ability to respond accurately.

·         Fire drills—Trained evaluators observe and question employees during each fire drill. Performance and knowledge is documented and sent to area leaders for reconciliation of problems. 

 

Performance Monitoring

 

The Hospital Environment of Care Committee and/or its subcommittees have established the following performance standards related to fire safety management.

 

1.                   The Hospital will demonstrate a state of readiness for fire prevention and response by scoring 95% or above on all sections of the semi-annual fire drill evaluation.

 

2.                   Hospital areas will demonstrate a state of readiness for fire prevention and response by scoring 95% or above on life safety/fire prevention during each safety inspection.

 

3.                   The Hospital will have no more than 25 false fire alarms per year. This standard was established based on comparison with benchmark institutions.

 

4.                   All fire extinguishers will be inspected monthly and inspections will be appropriately documented.

 

5.                   The Hospital will resolve all life safety code deficiencies listed on the SOC within the time frame specified.

 

Emergency Procedures

 

The Hospital has established a fire plan and an evacuation plan, documented in Hospital Policy and in the Emergency Management Plan. These plans are tested as a part of routine fire drills and emergency response exercises.

 

·         The fire plan outlines the facility-wide fire response needs and roles and responsibilities of staff at and away from the fire’s point of origin.

·         The evacuation plan outlines the roles and responsibilities of staff in preparing for transfer to area of refuge or building evacuation.

 

In cases in which departmental or unit needs require more detailed instructions, the department/unit has developed departmental policies and emergency procedures.

 

Emergency exit routes, established in consultation with the fire marshal, are posted in the Hospital lobby, elevator lobbies, and public waiting areas. The Physical Plant Division updates emergency exit route postings when construction or renovation causes a change to the facility.

 

Program Review and Evaluation

 

The Fire Safety Management Plan and related plans are evaluated annually by the Hospital Safety Officer, the Campus Fire Marshal, Medical Center PPD, and other Hospital/Medical Center representatives who have functional responsibility for life safety, using established questions/criteria. Results of this annual evaluation are presented to the Hospital Environment of Care Committee for review, recommendation, and approval.

 

All Hospital safety policies are reviewed at least bi-annually by the Hospital Safety Officer and other appropriate bodies or individuals. Results of this evaluation are presented to the Hospital Environment of Care Committee for review and recommendation. Hospital policies are distributed to staff on line or in hard copy.

 

 

Evaluated May 2004

Revised June 2004