Managing A Common Vulnerability and Saving Lives With Your Fire Suppression System

4 minutes

Historically, fire suppression systems and equipment are among the most frequently cited conditions on regulatory survey findings. While meeting standards with properly maintained automatic sprinkler systems can be a straightforward compliance component, ineffectively implemented oversight processes can result in continued citations, accreditation-impacting survey results, and worst of all—patient harm.   

Sprinklers: A Critical Component of Your Life Safety Strategy  

While seemingly evident, the National Fire Protection Association (NFPA) translates the importance of sprinklers into measurable outcomes, stating: 

  • The use of sprinklers in your building significantly reduces the chances of someone dying in a fire, but also reduces the chances of property loss by one-half to two-thirds (on average) when compared with buildings that are not completely protected by sprinklers. 
  • NFPA has no record of a fire killing more than 2 people in a completely sprinklered institutional building in which the system was working properly. 

The use of automatic sprinkler systems is so critical to ensuring the safety of people and property, the Centers for Medicare & Medicaid Services (CMS) requires all new* healthcare facilities (including ambulatory surgery centers and long-term care facilities) to be equipped with sprinkler protection. 

Pitfalls to Avoid 

While these outcomes are crucial in any facility including healthcare, the benefits can only be realized if sprinklers are working properly, which can often be overlooked.   

According to an NFPA study, when sprinklers fail to operate, the most common reason given (57% of the failure events) was the system having been shut off before the fire even began. It is not uncommon for sprinkler systems (or portions thereof) to be shut down during routine inspection or maintenance activities.   

Other factors in sprinkler failures include manual intervention that defeated the system (18%), lack of sprinkler system maintenance (10%), damage to sprinkler/component (9%), and inappropriate system for the type of fire (6%). But even when sprinklers work, issues can arise, often resulting from not enough water being applied to the fire.   

It is imperative to prioritize the proper functioning of healthcare facility sprinkler systems. As you are going through your life safety strategy, consider these questions: 

  • Are your plant operations staff communicating routine maintenance sprinkler shutdowns during safety huddles are other notification processes? 
  • Are your supplies and equipment stored 18 inches away from sprinkler deflectors? 
  • Do you have proper holiday decoration protocol, ensuring décor is not hung from sprinklers?  
  • Have you confirmed the accessibility of fire extinguishers in your environment are everyday practices for ensuring that (should one ever occur) the impact of a fire is minimized? 

Achieving Life Safety Compliance 

During the most recent American Society for Health Care Engineering Annual Conference, representatives from certain accreditation organizations spent time discussing the most frequently cited standards in physical environment surveys. They indicated findings related to sprinkler systems and equipment were well-represented in the top 10 most frequently cited Life Safety Code standards, further supporting the key impact sprinklers have on achieving Life Safety compliance.  

And often, a lot of those findings occur in hidden areas—above ceilings, behind locked doors—spaces not easily or frequently observed outside of the cursory look during rounds.    

Organizations that prioritize the safety of their physical environment and address vulnerabilities before the survey not only minimize their regulatory compliance risk but help create the safest possible environment for healthcare delivery. 


*As defined by CMS, “new” healthcare facilities include facilities, or portions thereof, with building plans that were approved after July 5, 2016 (the date CMS adopted the current edition of NFPA 101, Life Safety Code). Be sure and check the approval dates of your building plans to ensure your facility is compliant with sprinkler protection. 


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