Fire Safety Inspections in Healthcare Facilities: Streamlining the Process & Ensuring Compliance

Fire and life safety inspections are a must in every commercial building and industry. However, some industries have unique requirements that add an extra layer of complexity to the inspection process. Enter: healthcare facilities. With the presence of multiple stakeholders with different priorities and the importance of patient safety, healthcare facility inspections have their own set of challenges. Effectively conducting and reporting these fire safety system inspections while getting all the specific information required by each authority having jurisdiction (AHJ) and minimizing disruptions is vital for today’s technicians.

In a recent webinar, Inspect Point co-founder Drew Slocum sat down with Robert Gavin from RAEL Fire Protection, Greg Gumberts from Medxcel, and Andy Buttermore from Flashpoint Fire Protection LLC to discuss the challenges around healthcare facility inspections and how inspectors can modernize and improve the process for better compliance.

Meeting Different Fire Safety Standards

Healthcare facilities must comply with standards from various accrediting bodies–which can make compliance a challenge without the right contractors and the right tools. The Joint Commission is the most commonly used national accrediting body. But that’s not the only standard healthcare facilities need to meet. In addition to national accreditation standards, healthcare facilities must comply with standards from their local AHJs which may use specific NFPA code years. And certain states, localities, or insurers may have additional inspection forms that must be completed.

As an inspector, it’s important to have access to the right forms for each fire safety code area in each healthcare facility you inspect. Does the hospital submit reports to the Joint Commission? What other AHJs do you need to consider and prepare documentation for? Not only do different AHJs use different forms and adhere to different fire safety code standards, they may also require different inspection frequencies.

Ultimately, you have to ensure reports are coordinated appropriately. “When we first put together our Joint Commission reporting, the fire marshal looked at the report and asked, ‘What’s this?’” Gumberts explains. “That was too much information for them.” The idea is to “play nice in the sandbox” with each organization and their different requirements and priorities as they ensure the healthcare facility is compliant with relevant fire safety codes.

Coordinating & Communicating

You’re likely not the only business inspecting a particular healthcare facility. It’s important to consider your role in coordinating with other contractors to ensure the facility is compliant with each AHJ’s standards. The facility owns this coordination, but you provide essential support to ensure they meet all the requirements–including by performing a fully functional test, alongside other contractors, of all required fire safety systems within the timeframe provided by the AHJ. Because customers are on high-alert when it comes to their national accrediting body, they’ll be inclined to ensure proper coordination between different contractors. Supporting these coordination efforts and playing your role effectively keeps your customers happy and ultimately results in repeat business.

Concise documentation is essential. When surveyors can find the information they’re looking for from the get go, the process is easier for you and your customers.

Another key challenge is inspection frequency: “The biggest thing with the Joint Commission are the dates–they’re very strict about that,” Buttermore says. The Joint Commission “requires twenty systems be tested or inspected as often as weekly, monthly, quarterly and up to annually.” And the higher the frequency, the more challenges inspectors face when it comes to coordination–whether with other contractors or simply the facility itself. The goal should be to combine testing and inspection for as many fire and life safety system elements as possible to minimize disruptions while adhering to inspection requirements.

Often, healthcare facility standards prescribe a more inventory-intensive inspection, requiring inventory of all fire and life safety systems. “The report is the output, but the input is the inventory of assets,” Slocum says. Because no facility will want to pay for thousands upon thousands of barcodes for each individual alarm or sprinkler, finding the balance of an adequate inventory that satisfies the AHJ’s requirements is essential. Gumberts emphasizes, “Inventory has to be specific to Joint Commission performance elements…we go as far as we need to without going overboard.”

Modernizing Inspection & Compliance

With the advent of technology, why do so many healthcare facilities, inspectors, and surveyors still use paper? Gumberts explains Medxcel provides electronic files to healthcare facilities, who print out the reports for surveyors. “So many different avenues of data come into one presentation to the surveyor, so being able to print it out and provide it makes the process flow quickly,” he says. “The goal is mainly to get through document review and onto the building tour.”

Concise documentation is essential. When surveyors can find the information they’re looking for from the get go, the process is easier for you and your customers. Gavin agrees: “The Joint Commission has exactly what it wants on the report. Anything more is a reason to question.” A system that addresses exactly what is required by each AHJ and generates simplified, “no fluff” reports streamlines the inspection process and ensures compliance.

Streamlining Healthcare Facility Inspections

Inspect Point helps you do just that. “When we were reviewing different software platforms before we moved into the digital age, a clean report was important to us,” Gumberts says. With Inspect Point, inspectors can easily access the proper forms to satisfy national and jurisdictional AHJs and automatically generate and send concise reports for each one.

There’s a lot to consider when it comes to healthcare facility inspections. Be prepared to support your customers and provide exactly what they (and their AHJs) need. Learn more and view the webinar, “Improve Compliance with Inspect Point’s Unmatched Healthcare Capabilities,” on-demand.