The Importance of NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition Operations in Healthcare Facilities

Bruce Campbell + Shaine Grogan

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Aug 31, 2022

Healthcare facilities must protect patients, staff and the physical environment during construction. Regardless of construction type or method, buildings and other structures are more vulnerable to fire when they are under construction, alteration, or demolition than when demolition is completed. During construction, the absence or impairment of fire suppression and detection, means of egress, and compartmentation, along with the presence of heavier concentrations of readily ignitable combustibles, increases the likelihood of fires spreading more rapidly than expected during normal use.

In new construction, fires can more easily cause severe damage because of incomplete structural systems, lack of applied fire-resistant materials and the exposed condition of the structure. Using hot work in healthcare construction operations also increases the likelihood of a fire. Fires can destroy building materials stored on site, lengthy delays in project completion, long-term business interruption, injury or loss of life.

NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition Operations

NFPA 241 provides the guidance necessary to achieve a High-Reliability Organization's (HRO) goals and is the best standard to address hazards associated with construction in healthcare facilities. It is mandated in 42 states across the country where NFPA 1, Fire Code, or the International Fire Code (IFC) has been adopted and applicable to the means of egress in healthcare and ambulatory healthcare occupancies per NFPA 101 (as required by the Centers for Medicare & Medicaid Services [CMS]). NFPA 241 is organized into three areas:

  • Frontal matter (administrative, references, definitions)
  • Core matter (temporary construction, process and hazards, utilities and fire protection)
  • Specialized chapters (roofing operations, tall timber structures, underground operations and other operations)

The FPPM and Fire Prevention Plan

NFPA 241 requirements specify the designation of a Fire Prevention Program Manager (FPPM) responsible for keeping all personnel safe and ensuring the project is completed safely in accordance with all requirements. The FPPM has the authority and budget to implement NFPA 241 via a documented Fire Prevention Plan fully. Key elements of the NFPA 241 Fire Prevention Plan should be prepared by qualified personnel and include:

  • Fire Protection
  • Housekeeping
  • On-site security
  • Fire protection systems
  • Pre-fire plan
  • Communication system(s)
  • Special hazards
  • On-site fire brigade (emergency response personnel)

The Fire Prevention Plan is a vital document that sets forth the foundation necessary for coordination amongst various stakeholders within a healthcare facility. For example, healthcare facilities must provide elements necessary for a defend-in-place strategy, including passive fire protection features like smoke compartmentation.

Where such fire protection elements are impacted during construction in a healthcare facility, the hospital must manage the environment to reduce risk to the organization's employees. The healthcare facility must assess life safety code deficiencies per their interim life safety measure (ILSM) policy and determine how to compensate for increased life safety risk. Furthermore, fire procedures such as evacuation and relocation plans and fire drills may need to be altered for healthcare construction operations and then updated post-construction.

Protect Your Facility from Fire During Construction

Our team at Jensen Hughes takes pride in assisting healthcare facilities and those working at healthcare facilities with addressing the many challenges and considerations required to maintain life safety during construction operations. Learn more about how Jensen Hughes can help with the implementation of NFPA 241 and emergency preparedness in your healthcare organization.