Published on January 2, 2018.

Learning from Mistakes

A sample of compliance challenges for Baystate Medical Center

Beginning in 2012, shortly after the opening of its Phase 1 West Wing, Baystate Medical Center received repeated citations from The Joint Commission, a hospital-accrediting organization approved by the Centers for Medicare & Medicaid Services (CMS), for areas that were not in compliance with NFPA 101®, Life Safety Code®. At that time, code compliance was based on the 2000 edition of NFPA 101; CMS has since updated to the 2012 edition of the code. The corrections necessary to fix these issues consumed valuable resources and disrupted occupied patient care areas.

While the evidence-based design process does not specifically address code compliance, bringing together a multi-disciplinary team early in the design process helped Baystate mitigate these compliance issues and save money. The team was also able to consider code compliance solutions that supported the evidence-based design goals. The issues identified in The Joint Commission citations were reviewed as part of a process to help the Baystate design and construction teams avoid the issues from reoccurring.


Door undercuts
NFPA 101 references NFPA 80, Fire Doors and Other Opening Protectives, which limits door undercuts to a maximum of three-quarters of an inch for fire-resistance-rated doors. Larger undercuts can occur in new construction due to variations in the floor or the leveling of the door once it is hung. To allow for variations in floor construction, specifications should require a maximum door undercut of five-eighths of an inch.

Door kick plates
NFPA 80 allows for non-labeled door kick plates up to 16 inches. Fire-resistance-rated doors are frequently identified in our experience with non-labeled, field-applied kick plates greater than 16 inches above the floor. Fire-resistance-rated doors are permitted to have kick plates installed on the door if they are part of the door listing and appropriately labeled. The only exception to this is in NFPA 101, which allows for field-applied, non-rated protective plates to be installed on fire/smoke-rated doors in smoke barriers and to hazardous areas extending not more than 48 inches above the bottom of the door. These requirements should be reviewed and coordinated with the door schedule to ensure that any doors requiring kick plates comply with these provisions.

Door self-closing hardware
NFPA 101 requires many fire-rated doors in health care occupancies to be installed with automatic- or self-closing hardware. Door closers are frequently installed and set prior to air balancing, which can cause the failure of the doors to latch when closed. It is recommended that the closer settings be established after air balancing is completed, since pressure differentials can impact doors’ ability to close. Proper closing and latching should be field verified by opening the door to 90 degrees and releasing.

Door push-to-exit buttons
Access-controlled egress doors are required to be provided with a push-to-exit button as part of their hardware set, and NFPA 101 requires the hardware to be installed no more than five feet from the doors. We have observed these buttons installed more than five feet away from a door’s opening device. A process should be implemented during construction to ensure push-to-exit hardware is installed within the five-foot maximum.

Maintenance and inspection of fire and smoke dampers
NFPA 80 requires dampers to be installed with access doors no less than 12 inches square, or that are provided with removable duct sections. Fire and smoke dampers are frequently installed without a compliant means of access for proper maintenance and inspection. Unobstructed access is required to be provided through the ceiling or wall to gain entry to the access panel. The design specifications for dampers should be reviewed to confirm these requirements are clearly outlined, and that procedures exist during construction to ensure compliant access is provided.

Wall joints
NFPA 101 requires that the joints created at the intersection of fire-resistance-rated walls and floor/ceiling assemblies be protected with approved fire-stopping assemblies. During new construction or renovation projects, however, these joints are often left unprotected. During construction, it is recommended that the installation of the head of wall fire-stopping is reviewed prior to the installation of any drop ceiling or mechanical systems that would obstruct access.

Wall penetrations
NFPA 101 requires penetrations of fire-rated walls to be sealed with an approved fire-stop system. Wire sleeves are often left at the end of construction projects for information technology (IT) departments to run cables through, but these uncapped sleeves can result in through penetrations that compromise fire-rated walls. Coordination must occur between the IT and facilities and engineering departments, as well as with the contractor, to ensure sleeves are appropriately capped and sealed.

Visibility of exit signage
NFPA 101 requires that exit signage be installed in readily visible locations. Obstructions to exit signage can occur where pendant lighting or furniture have been installed without consideration to the visibility of the signs, and the installation of those features must be coordinated to avoid obstruction of exit signage sight lines.

Hand-rub dispenser installation
NFPA 101 prohibits the installation of alcohol-based hand-rub dispensers above ignition sources and within one inch horizontally or one inch below an ignition source. Alcohol-based hand rub dispensers are often found installed directly above electrical outlets and other ignition sources. The location of these dispensers should be coordinated with the electrical plans and reviewed after installation to ensure they are not located too close to ignition sources.


Maximize use of patient-care suites in the design.
In NFPA 101, suites allow for a reduction in the required clear width in corridors from 96 inches to 36 inches where serving fewer than 50 people, and 44 inches where serving an occupant load of greater than 50 people. On accreditation surveys, hospitals are frequently cited for carts projecting into the required clear width. Additionally, positive latching hardware is not required on doors within the suites.

Minimize the amount of fire-rated wall when performing a renovation or addition project.
In NFPA 101, smoke compartments are limited to a maximum of 22,500 square feet. A common architectural strategy with projects in existing buildings is to create a new smoke compartment in the work area so as not to create renovations in existing areas of the building. While this strategy can insulate the project from issues in the existing building, it also greatly increases the amount of fire-rated wall, which requires additional costs for fire-stopping and opening protectives. To address this issue, incorporate the end area with the existing smoke compartment strategy and make revisions as necessary to minimize the amount of fire-rated wall.

Include security staff in the design process
Required egress routes may overlap with security risks, which is why it is important to include the facility’s security staff as part of the design collaboration. Strategies to separate these routes were identified through design rather than expensive locking door hardware that often doesn’t meet the needs of the security team.

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