A Self-Assessment Guide for Health Care Organizations - IFC

Standard FSE.4 [Fire/smoke safety plans]
The organization plans and implements a program to ensure that all occupants are safe from fire, smoke, or other potential emergencies
in the facility.
Intent of FSE.4
Fire is an ever-present risk in a health care facility. Thus, every organization needs to plan how it will keep its occupants safe in case of fire or
smoke. The organization adopts preventive measures including:
• safe storage and handling of potentially flammable materials (e.g. flammable medical gasses such as oxygen);
• use of early warning/early detection systems such as fire patrols, smoke detectors and fire alarms;
• provision of suppression mechanisms such as water hoses, chemical suppressants, and sprinkler systems;
• managing hazards related to any construction in or adjacent to the patient-occupied buildings; and
• ensuring safe and unobstructed means of exit for patients, staff and visitors in the event of a fire.
Such plans and safeguards are required no matter what the age, size, or construction of the facility.
Measurable Element Look for Score Observations
What is required
1) The organization has a
program to ensure that all
occupants of the facility
are safe from fire and
smoke (or other non-fire
emergencies). A Fire Safety
Plan specifies
a. the frequency of
inspecting, testing, and
maintaining fire
protection and safety
systems,
b. the procedures for
safely evacuating the
facility in the event of
a fire or smoke,
c. the process for testing
(exercising all or a
portion of the plan), at
least twice per year,
d. the necessary training
of staff to effectively
protect and remove
patients when an
emergency occurs, and
e. the participation of
staff members in at
least one fire safety
test per year.
How is this element
assessed
A Fire Safety Plan contains all the
required elements.
There is evidence that the Plan is
continually updated, e.g. based on
regulatory changes, facilities
development and corrective actions
identified during regular testing of
the Plan.
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68 IFC Self-Assessment Guide for Health Care Organizations