COVID-19 RECOVERY - Products and Solutions to help your business move forward - Learn More



Managing Life Safety: Are Your Openings up to Code?

Grainger Editorial Staff

To most hospital employees, door openings perform a multitude of functions. They provide security and privacy, help protect confidential information and communications, route people though buildings, act as fire and smoke barriers, protect means of egress, and help regulate environmental conditions. Of course, sometimes doors are viewed as an impediment to one’s activities and are propped open. Most importantly, openings are designed to help us safely manage our facilities and provide required security functions.

Managing these openings is vital to the safety, security, and efficiency of every healthcare facility. Understanding how openings work and interact within the built environment is essential to ensuring occupant safety. Each year, standards organizations commit significant resources in collaborative efforts designed to enhance life safety and equipment performance. As a result, standards are updated on a cyclical basis in order to take advantage of advances in materials, technology, and emergency management practices.

With such attention given to the form and function of openings, making certain they are designed consistent with applicable building and life safety codes, are properly installed, and operate as expected can be a daunting task. Education for building code officials and Authorities Having Jurisdiction (AHJ) must be a continuous process. In order to ensure occupant safety, healthcare facility owners and operators need to have the same requisite knowledge.

NFPA 101 - Life Safety Code

Created out of concern regarding the frequency of deadly fires in the beginning of the 20th century, NFPA 101 - Life Safety Code has been adopted in most states as the code used to determine the safety of a structure. Though the Life Safety Code is not in itself a legal code, it has been adopted in its entirety by many of these jurisdictions and incorporated in state statutes

. The Life Safety Code is revised every three years. The most recent revision was in 2012. Among the literature distributed by the NFPA is the inspection checklist. The inspection checklist covers several physical areas of a facility including doors, egress arrangement, corridors and vertical openings.

The Joint Commission Inspections

One such organization that uses the Life Safety Code is The Joint Commission (TJC). Formed in 1951 and with over 17,000 healthcare organizations accredited through them, The Joint Commission is the healthcare industry's oldest and largest accrediting body (source, The Joint Commission and Centers for Medicare & Medicaid Services (CMS) have adopted NFPA 101 and currently use a Life Safety specialist on the survey team to determine if codes have been met.

Healthcare facilities have been required to adhere to the 2000 Edition of the Life Safety Code for many years, but the CMS has adopted the 2012 Edition which is taking effect in 2014, with TJC incorporating it into their accreditation surveys in the near future. Adopting the 2012 edition of the Life Safety Code has the potential to save hospitals billions of dollars by bringing required activities up to modern standards, but will also require expenditures to update areas of the facility that may not be current. Make sure to check with your AHJ to see what is mandated for your facility.

Are You Confident that You Can Pass an Inspection?

The Joint Commission requires healthcare facilities seeking accreditation to comply with Life Safety Code among other standards. Not surprising, a recent survey by The Joint Commission revealed that since 2009 the most frequently cited issue was lack of compliance with the Life Safety Code - 46% of providers surveyed (source:

Depending on the nature and severity of TJC findings organizations can be found in compliance or “requirements for improvement” may be identified. This means the organization needs to address specific compliance issues and provide TJC with evidence that these have been resolved.

Depending on the number of requirements for improvement, an organization might not be accredited. Although this is rare, it can end up in a conditional status or in a status of preliminary denial of accreditation (PDA).

Less serious or “supplemental findings” include issues where an organization can use its own internal review process for improvements. Approximately four months after a conditional or PDA status is made, TJC returns to the facility to ensure compliance has been met.

In addition to surveys by The Joint Commission, healthcare organizations may also be subject to “validation surveys” conducted on behalf of the CMS. These surveys verify the performance and findings of TJC process.

Since 2006, TJC has used an unannounced survey process. Rather than letting a hospital know in advance when they will be surveyed within a specific timeframe, administrators know only that the process will occur sometime before the third anniversary of their last survey. This change was implemented to ensure facilities are in a constant state of readiness.

In order to address the complexities of safety compliance, TJC recently added life safety specialists to the inspections team, elevating the importance and visibility of life safety code.

Source: Article Courtesy of Allegion PLC.

The information contained in this article is intended for general information purposes only and is based on information available as of the initial date of publication. No representation is made that the information or references are complete or remain current. This article is not a substitute for review of current applicable government regulations, industry standards, or other standards specific to your business and/or activities and should not be construed as legal advice or opinion. Readers with specific questions should refer to the applicable standards or consult with an attorney.

Featured Resources


Get more great content like this sent to your inbox.