How to prepare for NABH assessment on Fire Safety in Hospital & Nursing Home?

 Dr. Madhav Madhusudan Singh

NABH is committed to ensuring the quality & safety of hospitals and healthcare organizations. The Facility Management & Safety (FMS) Standard covers Fire & other hazards. The standards applicable for fire hazards are:

During the NABH assessment the team conducts a survey of the hospital on fire safety, they check the following documentary proof on fire safety issues and verify on the ground under the Facility Management & Safety (FMS) Standard, which covers Fire & other hazards. 

Following documents which the assessor wants to see 

1. Fire NOC
2. Hospital drawing building approved by Municipal corp / local Body
3. SOP on fire safety 
4. Maintenance plan register of Fire equipment including refilling of extinguisher
5. Fire safety mock drill register
6. Fire safety training register
7. Employment / Nomination letter of Fire Officer as per NBC guidelines

The standards applicable for fire hazards are:

 

NABH Standard	NABH objective element	Guidelines for objective elements	Relevance of objective element
FMS. 1: The organization is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements	FMS 1a	The management is conversant with the laws and regulations and knows their applicability to the organization.   Note: Assessors interact with management and assess about awareness about fire safety , NOC , bylaws.	Legal Compliance
FMS.2: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors	FMS 2b	Drawing related to Fire escape Routes (NBC guidelines)   Note : Hospital drawing building with fire escape marking should be available.	Infrastructure point of view
FMS.2: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors.	FMS 2c	Fire exit signage's ( NBC guidelines)     Note:  See note infra	Infrastructure point of view
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities.	FMS 5a	Fire exit plan for each floor displayed & in each patient Room ( NBC guidelines)   Note:  See note infra	Infrastructure Design point of view
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities	FMS 5a	Exit Door should remain open on all the time ( NBC guidelines)   Note:  See note infra	Infrastructure Design point of view
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities.	FMS 5a	Emergency illumination system in case of Fire ( NBC guidelines)     Note:  See note infra	Infrastructure Design point of view
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities	FMS 5a	Adequate Fire detection system across Hospital i.e. smoke & Fire sensors ( NBC guidelines)   Note:  See note infra	Infrastructure Design point of view
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities	FMS 5a	Adequate Fire Fighting system across Hospital i.e. sprinklars, extinguishers, hydrants ( NBC guidelines)	Infrastructure Design point of view
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities.	FMS 5a	Central Fire alarm system monitored 24 X 7       Note:  See note infra	Infrastructure Design point of view
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities	FMS 5a	Designated place for assembly of patients/staff in the event of fire.   Note:  See note infra	Operational point of view
FMS.2: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors.	FMS 2a	Operational & Maintenance plan of Fire equipment including refilling of extinguisher.       Note:  See note infra	Operational point of view
FMS.2: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors	FMS 2a	Up-to-date fire drawing to be available   Note: You have to provide building layout plan duly approved by municipal corporation.	Operational point of view
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities.	FMS 5a	Deployment of Fire Officer         Note:  See note infra	Operational point of view
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities.	FMS 5a	Adequate training plans for Hospital staff on how to protect patients from fire, how to evacuate patients from fire besides knowing how to report fire, nearest fire escape route, nearest fire extinguisher etc   Note:  See note infra	Operational point of view
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities.	FMS 5a	Schedule to conduct mock fire drills (at least twice in a year)	Operational point of view
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities.	FMS 5a	Maintenance of mock fire drills records	Operational point of view

 

 

Detail description:

FMS 2c : Fire exit signage ( NBC guidelines)

The size of Every fire exit sign must have the word EXIT or other appropriate wording in plainly legible letters not less than 6 in. (15.2 cm) high with the principal strokes of letters not less than 3/4 in. (1.9 cm) wide. The word EXIT shall have letters of a width not less than 2 in..

FMS 5a : Fire exit plan  & Building evacuation diagrams ( NBC guidelines)    

   General guidelines for building evacuation diagrams

• Keep it simple. Show the basic layout of the building (by floor level), including walls and doors.
• Make the sign large enough so that it is clearly seen.
• Color-code items on the sign to make them easier to understand.
• Post signs at or near means of egress, entrances to stairs, in elevator lobbies, and in any area where there are a lot of people.

 What to include in a diagram

• Identify the starting point with the words “You are here.” This will vary according to where the sign is posted.
• Provide a simple compass in one corner of the plan, showing north with the letter “N.”
• Mark the egress paths that are available from the starting point. Highlight exterior or stair enclosure doors with the word “Exit.”
• Show the location of fire extinguishers and manual fire alarm pull stations.
• Identify any outdoor gathering areas.

 

FMS 5a : Exit Door should remain open at all the time (NBC guidelines)

 Fire-rated doors are intended to be pushed open from inside the building. Fire doors typically stay unlocked, however, if secured, an approved lock is used. A fire door in the path of egress is usually equipped with a push bar to limit the contact .

FMS 5a :  Emergency illumination system in case of Fire ( NBC guidelines)

 Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level.

 Emergency escape lighting will illuminate signs, exit routes and doors, stairways, firefighting equipment, and more besides. They ensure that everyone can make a swift exit, even if they don't know the premises at all. And it's this type of lighting that the law says you must have.

 

FMS 5a :  Adequate Fire detection system across Hospital i.e. smoke & Fire sensors ( NBC guidelines)

 The two most commonly recognized smoke detection technologies are ionization smoke detection and photoelectric smoke detection. It should be placed in hospital. Min distance between two Fire smoke detector as per NFPA 72 is 30 feet spacing . The sensors are used for fire detection and will be checked on ground by assessors of NABH. In fire detection based on heat sensing, most current fire detection systems use electronic and distributed optical thermal detectors based on thermistors. Thermal sensing based on infrared is a helpful technique, especially appropriate for thermal detection of the targeted location.

 

 

 

FMS 5a : Central Fire alarm system monitored 24 X 7

 The central fire alarm system is installed at a location that is staffed 24/7.

  FMS 5a : A designated place for assembly of patients/staff in the event of fire

 The assembly point should be at least 50 feet away – that should be far enough away to be safe from the dangers of smoke inhalation, heat, falling debris and the possible collapse of the building. It must be positioned a distance equal to twice the height of the building. So, if a two storey building is 8 metres high, the assembly point must be 16 metres away from the building

 

 

 FMS 2a : Operational & Maintenance plan of Fire equipment including refilling of extinguisher.

 The assessors check the following things:

 

1. ·         Carrying out a visual inspection.
2. ·         Checking the extinguisher has not been used or tampered with.
3. ·         Taking a pressure gauge reading.
4. ·         Removing the discharge hose to check for blockages or corrosion.
5. ·         Weigh and clean the extinguisher.
6. ·         Ensure wall mountings are secure.
7. ·         All the registers of maintenance and extinguisher fillings details and sticker on extinguisher. 

The charging time of the fire waste extinguisher is generally 5 years. Recharge the form-type Fire extinguisher every 2 to 3 years. 

Fire extinguishers need to have an external maintenance examination conducted on a yearly basis, at the time of hydrostatic test, or when specifically indicated by an inspection discrepancy. Extinguishers need to have an internal examination conducted at anywhere from 1-6 year intervals depending on the type of extinguisher. For example, a dry chemical, stored pressure fire extinguisher must have an internal examination every 6 years, see NFPA 10 Table 7.3.3.1

 

Recordkeeping checked during NABH inspection

Each fire extinguisher shall have a tag or label securely attached that indicates that maintenance was performed. The tag or label needs to identify the following:

• Month and year maintenance was performed
• The person performing the work
• Name of the agency performing the work

Extinguishers also need a verification-of-service collar located around the neck of the container if an internal examination was conducted. That collar needs to have:

• Month and year the work was performed
• Name of the agency performing the work

 FMS 5a : Fire Safety Officer

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.

A qualified fire officer with experience not less than 3 yrs shall be appointed who will be available on the premises for all hospitals with height more than 30 mtr and above. Less than 30 mtr building trained personnel can be appointed, as no specific guideline mentioned.

(Auth : Letter no VII -110111/02 (Adv) /2020-DGCD (F) , Min of home affairs , GOI )

 

FMS 5a : Adequate training plans for Hospital staff

6 hrs minimum training is required every 6 mths for all staff including doctors

Will be followed in a next blog

 

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

https://twitter.com/madhavsingh1972

https://www.rfhha.org/

 

Additional reading:

1.      National Fire Protection Association (NFPA) 101 – Life Safety Code®

2.      National Fire Protection Association (NFPA) 5000 – Building Construction and Safety Code®

3.      International Code Council – 2018 International Building Code

4.      NBC part 4

 

Next blog:    What is the ideal fire safety drill for  hospital?