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Don’t End Up Paying Twice — Get Your Barrier Management Protocol in Place

Published on 6/16/2015

Firestops and barriers are consistently among the most frequently cited compliance shortcomings by healthcare facility surveyors.

Why the poor track record? It could be due to the sheer number of processes related to barriers, or the fact that in any given week countless trades and/or hospital personnel might come into contact with these areas. Or is it because too many facility managers still take a reactive approach to handling this critical area?

If penetrations made in a barrier are incompletely sealed (as all too often is the case), it’s because sealing is disregarded or misunderstood by those making the penetrations. Facilities are inviting not only citations and high repairs costs, but potential danger.

It is required under the NFPA Life Safety Code that all barriers be sealed and that hospitals protect personnel from the dangers of fire and smoke. Yet it’s a violation that is seen every day. Why expose your facility to these risks? Instead, become more proactive by establishing a Barrier Management Protocol.

When you have a proactive approach and a protocol in place, then your healthcare facility is not left holding the bag for vendors’ mistakes. What currently happens is that vendors come in, they make openings in the barrier and then they don’t seal them. The facility manager then has to hunt around and look for the problem through a barrier assessment, and you’re left to repair something you’ve already paid for. If you can get a protocol in place, then the healthcare organization is paying just once, not multiple times.

Effective Barrier Management Protocol Includes:

  1. A standard operating practice for the permitting of anyone entering a barrier.

  2. Documentation of all barriers and penetrations, reports on deficiencies and a focus on quality control throughout closeout inspections. Ideally this system should also document other processes in the barriers, i.e., dampers, doors and extinguishers.

  3. An accounting of who, what, when, where and how installations, maintenance and inspections in each barrier are being performed. Document the exact locations of these applications to provide your facility with a road map for future work.

About the Contributor: Kelly Mason is National Healthcare Manager for Specified Technologies, Inc. Mason speaks frequently on barrier management protocol and has provided training for The Joint Commission.