Fire Safety Requirements in Hospitals as per NABH Standards

                                                  Dr. Madhav Madhusudan Singh

The National Accreditation Board of Hospitals and Healthcare Providers (NABH) is an autonomous body under the Quality Council of India that provides accreditation to healthcare organizations in India. Fire safety is an important requirement for hospitals seeking accreditation from NABH.

Here are some of the fire safety requirements that hospitals need to adhere to as per NABH standards:

1.        The hospital should have a well-documented fire safety policy and procedure that is reviewed and updated regularly.
2.         The hospital should have a designated fire safety officer who is responsible for the implementation and monitoring of the fire safety policy.
3.     The hospital should conduct regular fire safety training for all staff members, including both clinical and non-clinical staff.
4.     The hospital should have appropriate fire detection and suppression systems, including smoke detectors, fire alarms, sprinklers, and fire extinguishers. These systems should be regularly inspected and maintained.
5.   . The hospital should have clear and visible fire exit signs and a well-marked evacuation route. The hospital should conduct regular fire drills to ensure that all staff members are familiar with the evacuation procedure.
6.         The hospital should have a clear policy for the storage and handling of flammable materials and chemicals.
7.        The hospital should have a clear policy for the management of patients who are unable to evacuate in case of a fire emergency.
8.    The hospital should have a documented plan for the management of fire emergencies, including coordination with local fire services.

 

Checklist

1. Firefighting equipment like wet riser, hydrants, auto sprinkler, fire alarm system, fire extinguishers of all types and sizes should be available as per table below (adapted from NBC 2016).

2. Operational and maintenance plan for firefighting equipment including refilling of extinguishers.

3. Up to date fire drawings to be available. Where applicable, the fire drawings should also specify the location of fire dampers.

4. Fire detection and smoke detectors exist across all floors. The detectors shall be tested for functionality at regular intervals, and records maintained.

5. Central fire alarm system is installed at a location which is staffed 24/7.

6. Fire exit plan for each floor. Exit door should be openable and free from any materials which will obstruct way.

7. Fire Exit signage on all floors well illuminated/ self-glowing, as per NBC guidelines.

8. Emergency illumination system in case power goes.

9. Designated place for assembly of patients and staff in case of fire.

10. Mock fire drill records and schedule of conduct of drills.

 

Legal Compliance:

It is mandatory for all hospitals to obtain No Objection Certificate from the concerned Fire Department before the building can be occupied.

The NOC is to be renewed every year.

NABH Survey:

During its survey process the NABH auditors look into the following to ensure that the organization is compliant with Fire Safety Regulations:

Fire Prevention and Control Infrastructure:

1. The organization has updated NOC from state Fire Department.

2. The organization has a multi disciplinary safety committee with a senior person as the chairman of the safety committee. The safety committee meetings are held at least once in 3 months. The minutes of the meeting are recorded and put up to the senior management.

3. The organization has a formally appointed Fire Safety Officer in-charge of all concerns related to Fire Prevention & Safety. The Fire Safety Officer should be preferably from Security Staff and should be aware of all fire safety protocols.

4. The organization has a written plan for Fire Prevention and Safety and has a Fire Safety Manual approved by the safety committee.

5. The organization has an Emergency Command Centre that becomes functional immediately whenever there is an emergency. There is a written protocol and written constitution of the committee, and the Fire Command Centre is update with the name of the members. A designated person has the responsibility of informing all the Emergency Command members.

6. The Fire Safety Manual has the following components:

1. ·         Plan for fire prevention & control.
2. ·         Systems for fire prevention & control.
3. ·         Maintenance Schedules/ SOPs for systems related to fire prevention & control
4. ·         Inspection protocols for fire safety installations.
5. ·        Codes for the announcement of fire-related emergencies, procedures, and communication protocols for the same.
6. ·        Responsibilities of different departments in case of fire.
7. ·        Procedures, frequency & protocols for mock drills.
8. ·        Constitution of Fire Fighting & Evacuation Teams.
9. ·        Evacuation Plan.
10. ·        Electrical Safety & System

7. A multi-disciplinary committee, which has Fire Safety Officer as a member, holds facility rounds at least once a year for non-clinical areas & twice a year for clinical areas. Fire Safety requirements are on the checklist of the said committee and the reports are submitted in writing to the safety committee.

8. The safety committee has a system whereby all fire safety concerns are addressed.

9. The mock drills are conducted, and the reports submitted to the safety committee. Necessary action is taken to address any issues that crop up during mock drills.

10. The fire exits are well defined and end on the ground floor or refuge area or any safe place decided by the management.

11. The Fire Signages are appropriate and placed at the right locations.

12. Emergency fire signages are glow in dark signages.

13. The Fire Signages are visible and are bilingual, with one local language.

14. The egress routes are free from any materials that would cause hindrance in evacuation.

15. The Fire Doors have a proper fire rating and open outside.

16. The Fire Doors preferably have panic bars.

17. The Fire Doors remain open at all times.

18. The Fire cabinets are open all the time.

19. The Manual Call Points have means to break the glass.

20. The Fire Alarm systems are properly tested and maintained and a record is kept for the same.

21. The Emergency Exit signs should be displayed prominently.

22. The stairwells used for evacuation are pressurized in case of fire emergency.

23. The lifts are not used in case of fire.

24. The HVAC system has appropriate fire dampers to prevent spread of fire that function properly in case of fire. The dampers are tested and have a regular preventive maintenance schedule.

25. All the equipment have an organized preventive maintenance schedule that is recorded, and stickers put on the equipment showing the date of preventive maintenance check and the next date for maintenance.

26. Appropriate type & number of fire extinguishers have been installed according to the type of fire that could take place.

27. The Fire Extinguishers have a regular preventive maintenance schedule and stickers are put showing the date of checking and the next scheduled date for checking.

28. 10% of Fire Extinguishers are used every year for checking the same.

29. The building has an approachable peripheral road around it for access by fire brigade.

30. The Fire Pump House is maintained properly, and the pumps have pressure gauges that have been calibrated and appropriate pressures are maintained in the fire hydrant & sprinkler lines.

31. There is a proper training program for handling fire emergencies and training records are maintained. The entire staff is imparted fire safety training.

32. The staff is aware of the fire fighting systems, responsibilities during fire emergencies, evacuation routes & techniques, conversant with the type of fire extinguishers and their area of use, trained to operate fire extinguishers, code announcements and assembly points in case of fire.

33. The organization has policies & protocols for storing, dispensing & use of flammable materials. Appropriate warning signs for flammables are displayed.

34. Electrical safeties are in place. Preventive maintenance & testing is done at regular pre decided intervals and are recorded and stickers affixed.

35. All electrical panels have a rubber mat in front of them.

36. The earthing system is tested regularly.

37. The UPS batteries are checked regularly by loading the same periodically to check any heating up etc.

38. There is proper ventilation in panel, UPS & equipment rooms to avoid overheating.

39. There is an approval from the Indian Explosives Department for bulk storage of Diesel & any other flammable material as per Indian Explosives Act, in case stored in bulk.

40. The pumps used for pumping fuel are of flame proof construction.

41. The Provisions are there to take care of fuel overflow.

42. Flues are properly insulated.

Overall, hospitals seeking accreditation from NABH need to have a comprehensive and well-implemented fire safety program that ensures the safety of patients, staff members, and visitors.

 

Dr. Madhav Madhusudan Singh MBBS, MHA , MBA , PhD

https://twitter.com/madhavsingh1972

https://www.rfhha.org/

 

Next blog:    What Documentary proof will be checked during  NABH assessment on fire safety in hospitals & Nursing homes?