Guide

Hospital fire safety: a CBAHI & JCI readiness checklist

The fire and life safety items surveyors look at most often — and how to keep them in order between surveys.

Compartmentation

  • Fire doors self-close and latch fully, with intact rating labels and nothing wedging them open
  • Penetrations through fire-rated walls and floors are sealed with listed firestop systems
  • Smoke barriers are continuous above ceilings

Means of escape

  • Corridors and exits are kept clear of equipment and storage
  • Exit signs are lit and emergency lighting is tested and recorded
  • Stairs and exit doors are unobstructed and correctly signed

Systems

  • Sprinkler heads are unobstructed with the required clearance below them
  • Fire alarm, sprinkler and smoke control tests are up to date with records
  • Portable extinguishers are inspected and tagged

High-risk areas

  • Medical gas rooms and oxygen cylinders are stored and separated correctly
  • Electrical, UPS and data rooms are free of combustible storage

People

Staff know their role in the fire plan, including defend-in-place for patients who cannot be moved, and drills are held and recorded as the applicable standards require.

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