Policy: It is the policy of the St. Joseph Mercy Health System (SJMHS- Ann Arbor, Oakland, Livingston, Brighton, Chelsea and St. Mary Mercy Hospital- Livonia) and associated satellite facilities to assure the safety of patients, visitors and staff coming to our facilities. During times where the level of safety is compromised due to construction, renovation, modernization or where otherwise deemed appropriate, this policy shall be followed to assure alternate actions are taken to compensate for known hazards. Scope: When construction, renovation, modernization or otherwise deemed appropriate activities are taking place, a Pre- Construction Risk Assessment (to be referred to as PCRA) shall be reviewed and documented to determine the scope of work and if an Interim Life Safety Measure(s) (ILSM) shall be implemented. Note the PCRA and ILSM also addresses: Noise, vibration, and dust Patient, employee and visitor safety due to known deficiencies of the Life Safety Code NFPA 101 Cutting, soldering or welding Work that impacts emergency service access The PCRA shall be conducted at least three (3) to four (4) weeks prior to construction, unless the work is unplanned. This project assessment determines the level of ILSM needed to compensate for hazards that will be caused due to construction activities. It is required that the PCRA and ILSM documentation be filled out in a collaborative effort, which includes but not limited to; the prime contractor and the SJMHS Facilities, System Safety Leader, Infection Control and Prevention and the Security/ Public Safety Departments. All projects are subject to periodic PCRA and ILSM evaluation(s), as determined by the SJMHS Project Manager, to assure the continued safety of the occupants within our facilities. Any significant changes in scope of work will require a new PCRA and ILSM form to assure safety continuity. This policy may also be used for routine work orders that are Life Safety in nature and cannot be completed within 45-days. Definitions/Abbreviations: SJMHS: St. Joseph Mercy Health System TJC: The Joint Commission BFS: Bureau of Fire Services aka: State Fire Marshal CMS: Centers for Medicare and Medicaid AHJ: Authority Having Jurisdiction PCRA: Pre-Construction Risk Assessment ILSM: Interim Life Safety Measure ICRA- Infection Control Risk Assessment ICPDR: Infection Control Project Design Review CSOR: Construction Site Observation Report NFPA: National Fire Protection Association EOC: Environment of Care or Environment of Care Committee 1
"Deemed appropriate": Whereas the SJMHS project manager considers a scope of work greater than routine and feels that an ILSM may be appropriate. Construction: is the process of creating and building infrastructure or a facility. Construction starts with planning, design, and financing and continues until the project is built and ready for use. Renovation: (also called remodeling) is the process of improving a broken, damaged, or outdated structure or portion thereof more than routine in nature. Modernization: (synonym: Renovate or remodel) to make modern or to give a modern appearance. SJMHS Project Manager: The department leader assigned to act on behalf of the Hospital to initiate, conduct and complete an assigned project which may be small or big in nature. Prime Contractor- The organization that has the overall responsibility of facility construction and renovation. Recordkeeping: It is the responsibility of the SJMHS Project Manager to manage, maintain and enforce all necessary paperwork associated with projects. There shall be a central location for documentation, however it is the sole responsibility of the SJMHS Project Manager to assure that all documentation is complete, current and inspection ready at all times. It is also the responsibility for the prime contractor to maintain all documentation and supporting paperwork. Procedure 2
1. Approved Project Each project, approved for construction, will be assigned an identifier for tracking. 2. Infection Control Project Design Review During the design process the project manager will utilize and identify potential risks prior to the PCRA using the Infection Control Project Design Review (ICPDR) Checklist. This checklist will cover the following: a. Project Type- Inpatient, ICU, Outpatient, Operating Room, etc b. Project Scope- New construction, renovation, mechanical, etc c. Project Requirements- Airborne Infection Isolation rooms, eyewash stations, hand washing sinks, etc d. HVAC/Water Systems- Fume hoods/biosafety cabinets, air handling units, humidification, etc e. Finishes The completion of the ICPDR will prepare the project manager for the upcoming PCRA and ICRA processes 3. Pre-Construction Risk Assessment Three (3) to four (4) weeks prior to construction, a Pre-Construction Risk Assessment (PCRA) will be conducted to identify potential life safety risks. Where demolition, construction, or renovation are to occur, the PCRA will identify hazards that could potentially compromise care, treatment and services in occupied areas of SJMHS. The PCRA shall be completed prior to the completion of the Interim Life Safety Measurse (ILSM) and Infection Control Risk Assessment (ICRA) forms. The PCRA will identify how construction may/will affect patient care areas, including the following: a. Disruption of utilities/essential services b. Noise precautions and procedures (impact, duration, time of day work conducted) c. Vibration precautions and prevention (tool use, demolition, distance) d. Emergency procedures e. Fire (Emergency Procedures) f. ILSM (assessment performed and measures discussed) g. Utilities (location of emergency shutoffs identified) h. Security (site security, access control) i. Traffic flow (alternative routes, signage) j. Dust (controls for reduction) k. Debris (removal and routing) l. Control of Odors (controls identified) m. Hazardous Chemicals (list provided and hazards discussed) n. Asbestos (identified and if abatement required) o. Lead (identified and if abatement required) 3
4. Interim Life Safety Measures (ILSM) a. ALL SJMHS construction projects MUST be evaluated for ILSM. This evaluation considers the impact on exiting, compartmentalization, fire detection and response systems, ignition sources, storage, debris, and other potential concerns. b. Determine if the impact is significant: i. In general, short duration projects that do not reduce the level of life safety below Life Safety Code requirements are not significant. An activity which takes place in a room with an intact door which does not penetrate walls generally does not require an ILSM. Activity that affects doors or walls for less than one shift generally does not require an ILSM. However, the SJMHS Project Manager may determine an ILSM is needed based on project complexity or other deciding factors. ii. Activities that block or compromise exit stairs, required exit corridors, exit discharge, fire alarm disablement, or fire suppression disablement for more than 4 hours will require an ILSM. c. The hospital is responsible for protecting all occupants during construction when the Life Safety Code is not being met. Upon completion of the PCRA, those projects in need of an ILSM shall implement the following measures as defined by The Joint Commission Elements of Performance LS.01.02.01. LS.01.02.01 EP1: The hospital has a written interim life safety measure policy that covers situations when the Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. This policy also includes criteria for evaluating when and to what extent the hospital implements LS.01.02.01, EP 2-15 to compensate for increased life safety risks. The criteria include the assessment process to determine when interim life safety measures are implemented. LS.01.02.01 EP2: When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital evacuates the building or notifies the fire department (or other emergency response group) and initiates a fire watch when a fire system is out of service more than 4 out of 24 hours or a sprinkler system is out of service 10 hours in a 24 hour period in an occupied building. Notification and fire watch times are documented. LS.01.02.01 EP3: When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Posts signage identifying the location of alternative exits to everyone affected. LS.01.02.01 EP4: When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Inspects exits in affected areas on a daily basis. The need for these inspections is based on criteria in the hospital s interim life safety measuer (ILSM) policy. 4
LS.01.02.01 EP5: When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Provides temporary but equivalent fire alarm and detection systems for use when a fire system is impared. The need for equivalent systems is based on criteria in the hospital s life safety measure (ILSM) policy. LS.01.02.01 EP6: When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Provides additional fire fighting equipment. The need for the equipment is based on criteria in the hospital s interim life safety measure (ILSM) policy. LS.01.02.01 EP7: When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Uses temporary construction partitions that are smoke-tight, or made of noncombustible or limited combustible material that will not contribute to the development or spread of fire. The need for these partitions is based on criteria in the hospital s interim life safety measure (ILSM) policy. LS.01.02.01 EP8: When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Increases surveillance of buildings, grounds and equipment, giving special attention to construction areas and storage, excavation, and field offices. The need for increased surveillance is based on criteria in the hospital s interim life safety measure (ILSM) policy. LS.01.02.01 EP9: When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Enforces storage, housekeeping, and debris-removal practices and reduce the building s flammable and combustible fire load to the lowest feasible level. The need for these practices is based on criteria in the hospital s interim life safety measure (ILSM) policy. LS.01.02.01 EP10: When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Provides additional training to those who work in the hospital on the use of fire fighting equipment. The need for additional training is based on criteria in the hospital s interim life safety measure (ILSM) policy. LS.01.02.01 EP11: When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Conducts one additional fire drill per shift per quarter. The need for additional drills is based on criteria in the hospital s interim life safety measure (ILSM) policy. 5
LS.01.02.01 EP12: When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Inspects and tests temporary systems monthly. The completion date of the tests is documented. The need for these inspections and tests is based on criteria in the hospital s interim life safety measure (ILSM) policy. LS.01.02.01 EP13: The hospital conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety. The need for education is based on criteria in the hospital s interim life safety measure (ILSM) policy. LS.01.02.01 EP14: The hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features. The need for training is based on criteria in the hospital s interim life safety measure (ILSM) policy. Note: Compartmentalization is the concept of using various building components (for example, fire-rated walls and doors, smoke barriers, fire-rated floor slabs) to prevent the spread of fire and the products of combustion so as to provide a safe means of egress to an approved exit. The presence of these features varies, depending on the building occupancy classification. LS.01.02.01 EP15: The organization s policy allows the use of other ILSMs not addressed in EPs 2-14. d. Once the PCRA is completed and it is determined that an ILSM is needed, the SJMHS Project Manager and Prime Contractor will work with the SJMHS Facility Manager and System Safety Leader to review the PCRA and create a project ILSM. e. Once the ILSM is completed and signed by the Prime Contractor, SJMHS Project Manager, Facility Manager and System Safety Leader, the ILSM Documentation will be posted: i. At all entry ways into the job site, ii. a copy to be provided to: Public Safety iii. a copy to be provided to: Facility Management. iv. a copy to be provided to: Planning, Design and Construction v. a copy to be provided to Infection Control vi. a copy to be provided to System Safety f. Should it be determined that the project does not have any impact on exiting, compartmentalization, fire detection and response systems, ignition sources, storage, debris, and other potential concerns do not need to develop a full ILSM. It should be documented as such on the ILSM checklist and filed in the project records. 6
5. Infection Control Risk Assessment (ICRA) After conducting a PCRA, the project manager will initiate the ICRA Permit process with a SJMHS Infection Prevention Specialist. Both parties will review the project ICPDR and PCRA for understanding and clarification. Based on the results of the review, the SJHMS Infection Prevention Specialist will prepare the Infection Control Risk Assessment- Matrix of Precautions for Construction & Renovation and review with the SJMHA Project Manager and Prime Contractor. The result of the review is as follows: A. Additions, eliminations and/or updates to the original Matrix will need to be revised by the SJMHS Infection Prevention Specialist. Any changes may need a final review or reading by the SJMHS Project Manager and Prime Contractor. B. The ICRA matrix must be signed by the SJMHS Infection Prevention Specialist, Project Manager, Facilities Director, Unit Manager(s) and the Prime Contractor. C. Once all the appropriate signatures are obtained, the permit is issued by SJMHS Infection Prevention and Control and must be visibly displayed on the jobsite throughout the duration of the project. 6. Proceed with Construction/Changes in Construction Conditions Once an ICRA permit and ILSM are completed for the project, construction work may proceed. During construction it is imperative that the following steps be adhered to throughout the duration of construction. A. Review the ICRA and ILSM once a week to ensure that the project still falls within the parameters of the intial ICRA permit and ILSM. B. Should the parameters of the initial ICRA permit and ILSM change, the SJHMS Project Manager must review the changes with the Prime Contractor and SJMHS Infection Prevention and Control. Should it become necessary, both the ICRA permit and ILSM should be revised/reissued to address major changes in the work and/or environment. 7. Weekly Construction Site Observation Reports The SJMHS Project Manager will review and process a Construction Site Observation Report (CSOR) weekly. The report will evaluate the current status of the ICRA permit and the ILSM. Any changes and/or discrepancies should be addressed or changed/updated in the ICRA permit and ILSM. 8. PDC Job Files Under the SJMHS PDC shared job files, the SJMHS Project Manager should file all paperwork as it relates to the ICRA permit(s) and ILSM(s) under the Safety file within the Project Information job file. 9. Noise and Vibration: Management of noise and vibration during construction or demolition is important for patient safety. Noise and vibration can have a severe negative impact on the ability of physicians and other caregivers to manage patient care and on the 7
comfort of patients, staff, and visitors. Every effort will be made to minimize the level of noise and vibration and the impact on individuals and equipment. 1. The potential for noise and vibration to disrupt patient care processes during the construction, demolition, or maintenance of buildings of will be evaluated prior to commencement of work. The evaluation will be documented on the Construction Noise and Vibration Assessment Form. 2. Each project determined to have the potential for generating sufficient noise and vibration to disturb patient care will have a noise management plan developed. A team consisting of representatives of clinical services affected, facilities management staff, and contractor representatives will develop the noise and vibration management plan. A project liaison will be designated for each project requiring the development of a noise management plan. 3. If a project has multiple phases during which the potential for disruptive noise and vibration is determined to exist, the noise and vibration management plan must reflect the specific noise and vibration issues associated with each phase. 10. Indoor Air Quality: Indoor air quality is an important aspect of the safety of the patients, visitors and staff. The requirements for air quality will be identified in the infection Control Risk Assessment (ICRA). Air Pressure Relationships (pos+/ neg-): All construction shall be maintained at negative air flow. This shall be made possible by installing an "air pressure gauge" i.e. Manometer gauge installed or other method acceptable to SJMHS Infection Control. The installation of this device as well as the daily documentation shall be the responsibility of the prime contractor for the entire duration of the project. The gauge installation and documentation shall be kept in place until temporary walls are removed, or until Infection Control and Facilities deems appropriate. Filter / Air Scrubber/ Negative Pressure Machine: Filter shall be checked and maintained according to the machine manufacture recommendations and shall be the responsibility of the contractor. 11. Fire Watch Requirements A fire watch is the physical inspection of a building when the fire alarm, sprinkler or other suppression systems are disabled or temporarily out of service. A fire watch is also required when a contractor is cutting, brazing, or welding. When these types of conditions are present the contractor is responsible for giving proper notification SJMHS PDC, Facilities personnel and Safety. The contractor will also be responsible for assigning their own appropriately trained personnel to any activity that requires a fire watch. The following describes minimal fire watch requirements for all SJMHS projects. 8
A. Disabled or Temporarily Disabled Fire Alarms, Sprinklers or Other Suppression Systems 1. Personnel assigned to a fire watch will not be assigned to other duties than those required for a fire watch. 2. Personnel assigned to a fire watch shall be trained, by their employer, and able perform specific duties and they must be familiar with the following: a) All building, occupancies and hazards involved b) Facility fire protection systems c) Facility manual and automatic detection and alarm systems d) Use of portable fire protection equipment e) The facility site-specific fire response plan 3. Fire watch personnel will not leave their assigned areas except in an emergency or is temporarily relieved by other fire watch personnel. 4. Fire watch personnel will use hospital phones and/or cell phone to notify the SJMHS Safety and call 911 to report any condition that may affect life and/or property safety. 5. Fire watch personel will check all permits for hot work being performed and/or completed. 6. Fire watch personnel will locate and check portable fire extinguishers for availability and usability. 7. Were applicable, the fire watch personnel will provide any temporary fire alarm equipment. 8. The fire watch personnel will check that affected area(s) are clear of any discarded packaging, excess paper and other combustibles that could ignite a fire. B. Cutting, Brazing and Welding 1. All contractors will complete and follow the appropriate SJMHS burn permit requirements and measures. 2. All contractors have the responsibility to ensure their workforce is properly trained on the safe operation of all equipment used to complete their task(s). 3. The contractor will appoint a fire watch personnel whenever any activity includes cutting, brazing and/or welding. This personnel must be able to perform the specific duties required of the fire watch as itt pertains to the work being performed. 9
4. A contractor must also train or provide the resources to be familiar with SJMHS such as: a) All building, occupancies and hazards involved b) Facility fire protection systems c) Facility manual and automatic detection and alarm systems d) Use of portable fire protection equipment e) The facility site-specific fire response plan 5. All contractors will supply the appropriate fire extinguisher or other fire protection and properly train their employess on the proper usage. 6. Personnel assigned to a fire watch during any cutting, brazing and welding activities will not be assigned to other duties than those required for a fire watch. 10