Does Your Hospital’s Fire and Life Safety Systems Comply With The New NFPA 4 Standard?

Dave LeBlanc

Learn more about how we can help with NFPA 4 planning and integrated fire and life safety systems testing in your facility.

Share this post

The Centers for Medicare & Medicaid Services (CMS), along with approved Accrediting Organizations like The Joint Commission, require active engagement from healthcare facilities for the proper inspection, testing, and maintenance of fire and life safety systems.

Hospitals are extremely regulated by multiple authorities having jurisdiction and for good reason. Hospitals are not simply evacuated in a fire or other emergency like an office building. Fire codes require a “defend-in-place” philosophy that relies on staff response, passive fire protection features (e.g., fire barriers) and increasingly complex active fire protection systems (e.g., sprinklers, fire alarms, doors closing, smoke control). Consequently, fire and life safety systems need to be designed, coordinated, installed, programmed, tested and integrated to protect the entire healthcare ecosystem, satisfy the overall holistic approach, and achieve the fire protection and life safety goals required for a defend-in-place strategy.

New NFPA 4 Standard For Integrated Testing

Requirements for testing end-to-end integration of fire and life safety systems can be found in NFPA 4, Standard for Integrated Fire Protection and Life Safety Systems Testing. NFPA 4 is applicable where the 2018 or 2021 editions of the International Building Code, International Fire Code, NFPA 101 Life Safety Code or NFPA 1 Fire Code is adopted. In many locations, this is already a requirement through the locally adopted building or fire codes. The NFPA 4 Standard deals with new and existing buildings, including healthcare facilities. For example, whenever a jurisdiction adopts NFPA 4, retroactively there is a five-year window to develop your integrated testing plan for the existing facility.

Role of The Integrated Testing Agent

NFPA 4 has identified the Integrated Testing Agent (ITa) as a new role to be held by a qualified individual. Ultimately, hospitals do not have a one-size-fits-all approach to fire and life safety. Different hospital areas need to meet fire and life safety goals specific to the various occupancies in the facility. For example, the main lobby, intensive care unit (ICU), maternity ward, post-anesthesia care unit (PACU), and operating room have unique and specialized needs.

The ITa is a critical player in the coordination, documentation, and testing of the interfaces between a hospital's different fire and life safety systems. The ITa coordinates and develops testing scenarios in an Integrated Testing Plan to verify proper integration and programming and document that the various systems worked together to achieve the common fire life safety goals as intended.

Challenges to Integrated Testing

Because hospital facilities are occupied 24 hours a day, 365 days a year, performing the required end-to-end compliance testing of fire and life safety systems - including fire alarm audibles/visuals, emergency lighting and systems on emergency generators, among others - becomes a real-world issue. Moreover, stakeholder input is required to achieve agreement on the various integrated test scenarios for the hospital and the development of the Integrated Testing Plan for integrated testing of the fire and life safety systems. This is a long process due to the complexities and facility coordination needed to implement and document compliance successfully. These NFPA 4 integrated processes and tests are performed in addition to the fire and life safety system inspection, testing, and maintenance required for CMS accreditation.

Get Started With Your NFPA 4 Planning

If you don’t control and coordinate the process now, the process will control you. Ask yourself the following questions:

  1. Have you selected an NFPA 4 Integrated Testing Agent for your healthcare facility?
  2. Have you started your preparation and coordination for NFPA 4?

Learn more about how Jensen Hughes can help with NFPA 4 planning and integrated fire and life safety systems testing in your facility.

Headshot of David J. LeBlanc

About the author

David J. LeBlanc
David LeBlanc, PE, FSFPE, is a Vice President, Strategic Advisor with over 30 years of fire protection systems, design, and fire and life safety code consulting experience.

Get in Touch

By completing the above form you have read, understood and accept our Privacy terms as well as our Cookie terms. Read our Privacy Policy.

Jensen Hughes ensures non-discrimination in all programs and activities in accordance with Title VI of the Civil Rights Act of 1964. If you need more information or special assistance for persons with disabilities or limited English proficiency, contact the Jensen Hughes Compliance Team at 410-737-8677 or compliance@jensenhughes.com. 

More blog posts from Jensen Hughes


Improving Environmental, Social, and Governance Standards in Hospitals + Health Care

Apr 19, 2023

Today's business climate forces hospitals and health care organizations to face contradictory decisions. Now more than ever, they are required to save every dollar they can through cost avoidance and stewardship.

Read more
Fire Safety and Emergency Preparedness in Nursing + Health Care Facilities

Apr 7, 2023

This year marks the 20th anniversary of two particularly devastating nursing home fires that occurred in Hartford, Connecticut, and Nashville, Tennessee, claiming the lives of 31 people.

Read more
The Importance of Performing and Managing Facility Inspections, Testing + Maintenance

Mar 23, 2023

Today’s buildings are part of a modern trend of larger structures. These larger structures not only require more advanced fire protection systems but also a more considered approach towards ensuring life safety for the occupants

Read more