Building a life safety plan for a multicampus health system can be a daunting task. Understanding what is required can be tricky, and often the place to start is with your state authority having jurisdiction.

These plans typically include construction-related documents such as life safety drawings that demonstrate inspection activity is performed properly. Keeping the plans accurate, easy to understand and updated are important, and knowing how to manage the risks associated with the physical environment will help bring the plan together. Think of the life safety plan as a program to manage the physical environment that starts with understanding the risks associated with each building in the organization. In addition to the buildings, risks apply to the equipment that is used to support the buildings and patient care as well as anyone who is in the buildings. 

When developing plans, health systems and individual facilities will be accountable to Centers for Medicare & Medicaid Services (CMS) requirements. A good place to start is with form CMS 2768R, Fire Safety Survey Report, which lists requirements based on the 2012 editions of the National Fire Protection Association’s NFPA 101®, Life Safety Code®, and NFPA 99, Health Care Facilities Code.

Another document that can be useful is the CMS State Operations Manual, Appendix I — Survey Procedures for Life Safety Code Surveys, which identifies what CMS looks for at any CMS-accredited building included in the health system’s various licenses or certification numbers. 

To help understand this, CMS notes that NFPA 99 and NFPA 101 will apply to any building, “including those that do not house residents or patients on a 24-hour basis. This situation is most common in large campus-type facilities such as medical centers, teaching hospitals, or large state-operated intermediate care facilities for individuals with intellectual disabilities.” 

Remember, a good program has policies and procedures that meet the CMS requirements. These documents define the program procurement and oversight to ensure the physical environment is managed properly.

John Maurer MBA, CHFM, CHSP, SASHE, CLSS-HC, accreditation advisor, Vizient.