Fire + Smoke Doors in Health Care Facilities: Designing Your Door Performance Improvement Program

Matthew Icenroad

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Mar 14, 2023

Fire doors are crucial to hospitals and other health care facilities vulnerable to fires due to the presence of combustible materials and patients with limited mobility. In health care settings, fire barriers reduce the spread of fire and smoke and create compartments that provide safe areas for horizontal evacuation. By maintaining properly functioning fire doors, health care facilities can help ensure the safety of patients, staff and visitors in the event of a fire.

NFPA 80 Compliance for Health Care Facilities

To ensure the effectiveness of fire doors in health care settings, the Centers for Medicare & Medicaid Services (CMS) require organizations to comply with the guidelines set forth in NFPA 80 for fire and smoke barrier installation, inspection, testing and maintenance. NFPA 80 covers a range of topics, including fire door assemblies, fire windows, fire dampers, access panels and more. Regular inspections and maintenance to comply with NFPA 80 can help identify any issues that may compromise the integrity of the fire doors and allow for prompt repair or replacement, if necessary.

Fire + Smoke Barrier Inspection Criteria

In addition to reducing costly repairs, inspections help ensure that fire doors and life safety features work properly in the event of a fire. The following are some of the criteria that should be checked during a fire door inspection:

  • Proper labeling. All fire doors should be labeled with a permanent tag that indicates the manufacturer's name, date of manufacture and fire rating.
  • Clearances. The gap between the door and frame should not exceed the manufacturer's specifications, and the clearance at the bottom of the door should not exceed 3/4 inch.
  • Door operation. The door should open and close smoothly and latch properly when released. There should be no signs of damage or wear that could affect the door's operation.
  • Closing speed. The door should close from the open to the latched position without slamming or bouncing back.
  • Latching hardware. The latching hardware should be properly installed and functioning, including the latch bolt, strike plate and any other components.
  • Glass panels. If the fire door has glass panels, they should be labeled as fire-rated and installed with fire-rated glazing and framing.
  • Seals and gaskets. The seals and gaskets around the door should be intact and in good condition with no signs of wear or damage.
  • Frame and anchors. The door frame and anchors should be securely attached to the wall and in good condition with no signs of damage or corrosion.
  • Auxiliary hardware. Auxiliary hardware, such as door closers, kick plates or hold-open devices, should be properly installed and functioning.

It is recommended that fire door inspections be performed by qualified professionals who are familiar with applicable standards and regulations. Regular inspections and maintenance can help identify any issues and ensure that fire doors are functioning properly and providing the necessary protection in the event of a fire.

Fire + Smoke Barrier Performance Improvement Program

To ensure regulatory compliance and the life safety features of fire and smoke doors, health care facilities should develop and maintain a proper door performance improvement program. Designed to ensure proper door operation and maintenance in health care settings, this comprehensive plan typically includes:

  • Policies and procedures. The program should include clear policies and procedures for the inspection, testing, maintenance, repair, and replacement of fire doors as well as guidelines for documentation and record keeping.
  • Training and education. Staff and contractors involved in the installation, inspection, and maintenance of fire doors should receive appropriate training and education on the importance of fire door safety, relevant standards and regulations, and proper techniques for inspection and maintenance.
  • Inventory and assessment. An inventory of all fire doors in the facility should be created, and each door should be assessed for compliance with relevant standards and regulations.
  • Corrective actions. Any deficiencies or non-compliance issues identified during the assessment should be addressed through a structured corrective action plan, which may include repairs, replacements or upgrades as necessary.
  • Performance monitoring. Regular monitoring of the program's effectiveness should be conducted through ongoing inspections, testing and evaluation as well as analysis of performance data and feedback from staff and stakeholders.
  • Continuous improvement. The program should be reviewed and updated periodically to ensure ongoing compliance with applicable standards and regulations and incorporate best practices and lessons learned from experience.

Implementing a health care fire door performance improvement program can help ensure that fire doors are properly installed, inspected and maintained, reducing the risk of fire-related injuries and failures in health care settings.

Actionable Data from Digital Tools to Reduce Costs

Historically, organizations have utilized paper-based processes to maintain proper door inventories, inspection results and program goals. This approach is limited in its ability to properly track and trend the inspection results of the door inventory and can prevent the organization from effectively identifying the root causes surrounding inspection failures.

Using a dedicated door inspection tool, organizations can make real-time inspection results more available and utilize the data to drive better outcomes. For example, a door that regularly fails its annual inspection may create significant financial burden for the organization, as the door must be repaired or replaced on an annual cycle. By understanding the failure types, the door could be put on a quarterly inspection performance plan, allowing the organization to catch deficiencies early and reducing the need for costly repairs.

Furthermore, by engaging with shared and accessible inspection data, engineering staff can provide performance-based metrics to other departments and business units to better understand door failures around the facility. This may include doors located by the bed storage room. If this door routinely fails inspection, the organization can conduct a root cause analysis to understand why it is failing and develop a program to bring the door back into compliance.

Lastly, data-based programs may support organizations by helping them understand changes in their environments, practices, procedures and resources as well as how those changes may impact their door program. For example, if an organization has changed a vendor or the type of door hardware they use to make repairs, and door results are showing more hardware failures, data-based applications can help determine if the changes are correlated. Performing further analysis of this data can save the organization time, money and resources.

Stay Compliant and Improve Your Door Program

NFPA 80 compliance is crucial for health care facilities to ensure the safety of patients, staff and visitors in the event of a fire. Regular inspections and maintenance of fire doors can help identify any issues that may compromise their integrity and allow for prompt repair or replacement, if necessary. A health care facility should develop and maintain a door performance improvement program, including policies and procedures, training and education, inventory and assessment, corrective actions, performance monitoring, and continuous improvement.

Digital tools can support this program and drive better outcomes by creating access to real-time inspection results and data analysis while also reducing the risk of fire-related injuries or failures. By following these guidelines and using these tools, health care facilities can enhance the safety and security of their facilities, ultimately improving patient care and satisfaction. Learn more about Jensen Hughes health care solutions and the ProtectAdvisr solution platform, which includes a door inspections app.