The American Society for Health Care Engineering (ASHE) provides its members with a Life Safety Risk Assessment Tool, which has been developed by an ASHE task force.

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This tool provides a matrix of risk tolerance that allows an organization to determine the severity of an occurrence and the impact of the deficiency. The tool is used by cross-referencing the risk tolerance and severity of the deficiency to help determine steps that can be implemented to mitigate deficiencies in the National Fire Protection Association’s NFPA 101®, Life Safety Code®

By selecting one of four impacts and crossing with one of four severities, the risk tolerance can be determined for the deficiency in question. 

The “impact of deficiency” on the tool is broken up into four categories:

  1. Facility wide: Impacts the entire facility.
  2. Multiple units/floors: Impacts multiple smoke compartments.
  3. Local/single unit: Impacts a single smoke compartment or area.
  4. Short duration: Correction can be performed during the shift identified. 

The “severity of occurrence” is also broken up into four separate categories:

  • Category 1: Life safety deficiency likely to cause major injury or death.
  • Category 2: Life safety deficiency likely to cause minor injury.
  • Category 3: Life safety deficiency not likely to cause injury.
  • Category 4: Life safety deficiency likely has minimal impact to safety. 

Using these factors and placing them on the Life Safety Risk Assessment Tool can determine if the deficiency is high, medium, low or no interim life safety measures (ILSMs) are required. The instructions tab will assist in the process and give many examples of common deficiencies that may be found in a facility. However, these are just examples; each deficiency will be unique to a specific risk tolerance. When using this tool, facilities managers should be sure to include it in their ILSM policy and obtain approval through their Environment of Care Committee, if possible.