University of Arkansas for Medical Sciences. Part IV - Fire Prevention & Life Safety Management Plan FY18

Transcription

1 University f Arkansas fr Medical Sciences Part IV - Fire Preventin & Life Safety Management Plan FY18 I. MISSION The purpse f this plan is t prmte, implement and administer a cmprehensive Life Safety prgram fr UAMS. This plan prvides fr and mnitrs a safe envirnment fr emplyees, students, patients, and visitrs designed and maintained t cmply with the Life Safety Cde (LSC), Natinal Fire Prtectin Assciatin (NFPA) and the Arkansas Fire Preventin Cde. Design criteria accepted by the healthcare cmmunity are used when designing the envirnment f care including the Guidelines fr Design and Cnstructin f Hspitals and Healthcare Facilities, 2010 editin, published by The Facility Guidelines Institute II. SCOPE The Fire Preventin & Life Safety Management Plan establishes the parameters within which a safe and secure envirnment f care is established, maintained and apprved fr UAMS. Fire Preventin & Life Safety are established t ensure that emplyees are educated, trained, and tested in the fire preventin & life safety features f the physical envirnment and are able t react t a variety f emergency situatins that may affect the safety f ccupants r the delivery f health care. III. AUTHORITY / ORGANIZATION The Safety Crdinating Cmmittee (SCC) has authrity t crdinate and administer the UAMS Fire Preventin & Life Safety Management Plan and its resulting plicies. Prgram implementatin is the jint respnsibility f the Departments f Occupatinal Health and Safety (OH&S), Design & Cnstructin, Facilities Planning and Design and Engineering & Operatins. UAMS Envirnment f Care (EOC) Cmmittee members includes representatives frm OH & S, Engineering & Operatins, Design & Cnstructin, Facilities Planning and Design, Clinical Engineering, Telecmmunicatins, Plice, and Supprt Services. UAMS EOC Cmmittee member gals and respnsibilities are develped and reviewed as part f the annual evaluatin. The EOC Cmmittee Chair has been given the authrity by the Chancellr t rganize and implement the Fire Preventin & Life Safety Management Plan. The EOC Cmmittee will evaluate the trends and infrmatin gathered by the cmmittee, develp apprpriate plicies and prcedures, understand applicable cdes and regulatins, and evaluate the effectiveness f the Fire Preventin & Life Safety Management Plan and its cmpnents n an annual basis. Respnsibilities f the EOC Cmmittee include reprting significant findings and recmmending actins t the Safety Crdinating Cmmittee r the Vice Chancellr f Campus Operatins. IV. RESPONSIBILITIES / FUNCTIONS The EOC Cmmittee is respnsible fr: Review and apprval f all pertinent plicies. Review and apprval f the PM Maintenance Prgram. Oversight f the Fire Drill Prgram. Annual Evaluatin f the Fire Preventin & Life Safety Management Plan s bjectives, scpe, perfrmance, and effectiveness. 25

2 The Department f OH&S has management, enfrcement and audit respnsibility fr all f the fire preventin & life safety prgrams including: Recgnitin and reprting f safety issues related t facilities, equipment, and cnditins via envirnmental runds and the department specific audit prgram. Management f the Life Safety Cde Database (LSCD). Scheduling, cnducting, and evaluating all fire drills and actual fire respnses. Reprting and investigating life safety cde deficiencies in existing buildings and in new designs by plan review. Implementatin f Interim Life Safety Measures and respnsibility fr mnitring and training. Assisting in the training f all cntractrs wrking in UAMS campus facilities. The UAMS Engineering & Operatins Department is respnsible fr: Fire Alarm and Detectin Equipment is Tested in Accrdance with NFPA 72 as fllws: Initiating Devices All supervisry signal devices (except valve tamper switches) are tested at least quarterly. All valve tamper switches and water flw devices are tested at least semiannually. All duct detectrs, electrmechanical releasing devices, heat detectrs, manual fire Alarm bxes, smke detectrs are tested at least annually. Kitchen autmatic fire extinguishing systems are inspected fr prper peratin at least semiannually (actual discharge f the fire extinguishing system is nt required) in accrdance with NFPA 96. Carbn dixide and ther gaseus autmatic fire extinguishing systems are tested fr prper peratin at least annually (actual discharge f the fire extinguishing system is nt required) in accrdance with NFPA 12 and NFPA All prtable fire extinguishers and standpipe systems are inspected, tested and maintained as fllws: All prtable fire extinguishers are inspected, tested and maintained in accrdance with NFPA 10 as nted belw: 1. Clearly identified 2. Inspected at least mnthly 3. Maintained at least annually All stand pipes, hse cabinets, and fire sprinkler systems are inspected, tested and maintained in accrdance with NFPA 25. All fire pumps are inspected and tested in accrdance with NFPA 20. Building Fire Prtectin Equipment is maintained as fllws: All fire and smke dampers are perated (with fusible links remved where applicable) t verify they fully clse at least every six years in accrdance with NFPA 90A. 26

3 All autmatic smke detectin shutdwn devices fr air handling equipment are tested at least annually in accrdance with NFPA 90A. All hrizntal and vertical sliding and rlling fire drs are tested fr prper peratin and full clsure at least annually in accrdance with NFPA 80. The UAMS Design & Cnstructin Department is respnsible fr: Implementatin f the ILSM/ICRA Prgram Respnsible fr training f cntractrs cncerning the UAMS plicies and prcedures pertaining t cnstructin prjects. The UAMS Facilities Planning and Design is respnsible fr: Designing all newly cnstructed and existing envirnments f care in accrdance with the Life safety Cde (LSC), NFPA Using design criteria that are referenced by the healthcare cmmunity. Maintaining and updating the esoc. Reviewing Prpsed Acquisitins f Bedding, Windw Draperies, and ther Curtains, Furnishings, Decratins, Wastebaskets, and Other Equipment fr Fire Safety: Reprting and Investigating Fire Prtectin Deficiencies, Failures, and User Errrs: The Fire Preventin & Life Safety Management Prgram identifies and dcuments fire prtectin deficiencies, failures, and user errrs that may threaten the patient care envirnment. These issues are dcumented via Hazard Reprts, Maintenance Wrk Orders, Fire Drill Critiques, Interim Life Safety Inspectin Frms, Envirnmental Runding, r Departmental Specific Audits. Summaries f the reprts are prvided t the EOC Cmmittee. When prblems are identified, actins are taken t reslve them and such actins are dcumented. V. TRAINING AND EDUCATION: The UAMS Educatin Prgram incrprates an rientatin prgram fr new emplyees and annual in-service educatin fr existing emplyees. Bth training prgrams are designed t enhance emplyee safety awareness in an effrt t eliminate, as much as pssible, ptential safety hazards. The Orientatin and Annual Educatin Prgram addresses the fllwing: Specific rles and respnsibilities f persnnel, physicians, and ther licensed independent practitiners at a fire s pint f rigin. Specific rles and respnsibilities f persnnel, physicians, and ther licensed independent practitiners away frm a fire s pint f rigin. Specific rles and respnsibilities f ther persnnel wh must participate in the fire plan, such as vlunteers, and students. Use and functining f fire alarm systems. Specific rles and respnsibilities in preparing fr building evacuatin. Lcatin and prper use f equipment fr evacuating r transprting patients t areas f refuge. Building cmpartmentalizatin prcedures fr cntaining smke and fire. Training may als be cmpleted with annual refresher training requirements thrugh Scheduling OH&S t present a custmized presentatin 27

4 Review f the Safety in-service Mdule Mail ut f safety review mdule Review f vide presentatin VI. INFORMATION COLLECTION & EVALUATION SYSTEM (ICES): Infrmatin frm departmental specific audits, envirnmental runds and cnstructin prjects are cmpiled by the OH&S department. Life safety cde infractins that are identified are entered int the LSC database and transmitted t the Engineering & Operatins fr crrective actin. The LSC Database tracks all reprts f ptential hazards by department, categry f hazard, reslutin and time until cmpletin. VII. PERFORMANCE IMPROVEMENT INDICATORS FOR FY18: UAMS will extend last year s bjectives and maintain nging mnitring f perfrmance regarding actual r ptential risk within the Fire Preventin & Life Safety Management prgram related t ne r mre f the fllwing: Increase Air Pressure Relatinship perfrmance scres t >=90% in all patient areas Increase Smke/Fire wall damage perfrmance scres t >=90% in all patient areas Increase Dr Cmpliance perfrmance scres t >= 90% in all Business Occupancies. Increase Cleanliness f Envirnmental Services Supprt areas perfrmance scres t >=90% in all patient areas Perfrmance mnitrs are established and mnitred by OH&S and summary reprts are prvided t the Envirnment f Care and Safety Crdinating Cmmittee. The measures are mnitred as lng as deemed necessary by OH&S and the verall effectiveness f the perfrmance mnitrs are assessed as part f the annual evaluatin f the Fire Preventin & Life Safety Management Prgram. ANNUAL EVALUATION: The bjectives, scpe, perfrmance, and effectiveness f the Fire Preventin & Life Safety Management prgram is evaluated annually and reviewed by the Envirnment f Care & Safety Crdinating Cmmittee. The fllwing aspects f the prgram will be assessed: Increase the Air Pressure Relatinship perfrmance scres. Increase awareness f Smke/Fire wall damage in all patient areas. Increase Dr Cmpliance perfrmance scres. Increase Cleanliness f Envirnmental Services Supprt areas in all patient areas. The evaluatin will fcus n the results f the prgram ver the past year and quantitative data will be used as much as pssible. STATEMENT OF CONDITIONS: The UAMS Facilities Planning and Design Department is respnsible fr develping and maintaining an electrnic Statement f Cnditins (esoc) fr all applicable buildings. The hspital maintains an n-ging effrt t assess the facility fr cmpliance with the 2012 Life Safety Cde and keep the facility in cmpliance with the Cde. The esoc is an embdiment f UAMS n-ging effrts t keep its facilities in cmpliance with the Life Safety Cde. 28

5 VIII. Crrespnding Plicies: Interim Life Safety Measures (ILSM) and Infectin Cntrl Risk Assessment (ICRA) Campus Operatins, Infectin Cntrl: Cnstructin Areas Infectin Cntrl plicy Maintenance f Smke/Fire Barriers Campus Operatins UAMS Cntractr/Cnsultant Orientatin Design & Cnstructin Ht Wrk Permits Campus Operatins