Firestops and barriers are
consistently among the most frequently cited compliance
shortcomings by healthcare facility surveyors.
Why the poor track record? It
could be due to the sheer number of processes related to
barriers, or the fact that in any given week countless trades
and/or hospital personnel might come into contact with these
areas. Or is it because too many facility managers still take a
reactive approach to handling this critical area?
If penetrations made in a barrier
are incompletely sealed (as all too often is the case), itís
because sealing is disregarded or misunderstood by those making
the penetrations. Facilities are inviting not only citations and
high repairs costs, but potential danger.
It is required under the NFPA
Life Safety Code that all barriers be sealed and that hospitals
protect personnel from the dangers of fire and smoke. Yet itís a
violation that is seen every day. Why expose your facility to
these risks? Instead, become more proactive by establishing a
Barrier Management Protocol.
When you have a proactive
approach and a protocol in place, then your healthcare facility
is not left holding the bag for vendorsí mistakes. What
currently happens is that vendors come in, they make openings in
the barrier and then they donít seal them. The facility manager
then has to hunt around and look for the problem through a
barrier assessment, and youíre left to repair something youíve
already paid for. If you can get a protocol in place, then the
healthcare organization is paying just once, not multiple times.
Effective Barrier Management
A standard operating practice for the
permitting of anyone entering a barrier.
Documentation of all barriers and
penetrations, reports on deficiencies and a focus on quality
control throughout closeout inspections. Ideally this system
should also document other processes in the barriers, i.e.,
dampers, doors and extinguishers.
An accounting of who, what, when, where and
how installations, maintenance and inspections in each
barrier are being performed. Document the exact locations of
these applications to provide your facility with a road map
for future work.
About the Contributor
Kelly Mason is National Healthcare Manager for Specified
Technologies, Inc. Mason speaks frequently on barrier management
protocol and has provided training for The Joint Commission.
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