GOOD PRACTICE NOTE

IFC Life and Fire Safety: Hospitals

Good Practice Note – IFC Life and Fire Safety: Hospitals | i

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ii | Good Practice Note – IFC Life and Fire Safety: Hospitals

This Good Practice Note (GPN) was prepared by the consulting firm FPC Risk and
peer reviewed by John Graham, Luis Cestari, and Elena Chuzhakova (all IFC).

This GPN is intended to be used as a reference for IFC’s investment and project
teams. It is not intended to be a compliance guide or substitute for IFC’s Performance
Standards or the World Bank Group’s Environmental, Health and Safety Guidelines.

The purpose of the Good Practice Series is to share information about private
sector approaches for addressing a range of environmental and social issues,
that IFC believes demonstrate one or elements of good practice in these areas.
Information about these approaches may be taken from publicly available or
other third party sources. IFC and/or its affiliates may have financial interests
in or other commercial relationships with certain of the companies.

While IFC believes that the information provided is accurate, the information is
provided on a strictly “as-is” basis, without assurance or representation of any kind.
IFC may not require all or any of the described practices in its own investments,
and in its sole discretion may not agree to finance or assist companies or projects
that adhere to those practices. Any such practices or proposed practices would
be evaluated by IFC on a case-by-case basis with due regard for the particular
circumstances of the project.

For more information on IFC’s commitment to sustainability, including links to

the Sustainability Framework, visit www.ifc.org/sustainability.

Good Practice Note – IFC Life and Fire Safety: Hospitals | iii
Table of Contents
List of Abbreviations v

Introduction 1

1. Health Care Occupancies-Specific Fire Risks 3

2. Life and Fire Safety Components 3

Approach - “Defend-in-place” 3
Structural Fire Resistance 4
Fire Compartmentation 5
Interior Finish 8
Furnishings, Mattresses, Decoration 8
Fire Detection 10
Fire Alarm 11
Means of Egress 13
Fire Control and Suppression 17
Smoke Control 19
Protection from Fire Hazards 21

3. Documentation 25
Fire Safety Master Plan 25
Fire Safety Design Documentation 25
Fire Prevention Program 26
Management of Change Program 26
Emergency Response Plans 26
Maintenance Plan and Contract for all Fire Protection Systems 27
Test Plans for all Fire Protection Systems 27
Incident Reporting Documents 27

4. Fire Safety Project Approaches 28

5. Project Approval 26

Annexes 30
Annex A. Guideline Key Life and Fire Safety Design Principles 30
Annex B. Key Life and Fire Safety Audit Aspects 32
Annex C. Inspection and Maintenance Schedule 36
Annex D. Life and Fire Safety Documentation and Approval Flow 40

iv | Good Practice Note – IFC Life and Fire Safety: Hospitals

List of Abbreviations
dBA decibel (A-weighting)

FACP Fire Alarm Control Panel

GPN Good Practice Note

IFC International Finance Corporation

LFS Life and Fire Safety

m meter

m.s-1 meter per second

MAC Manual Alarm Callpoint

min minutes

N Newton

Pa Pascal

SHEVS Smoke and Heat Exhaust Ventilation System

WBG World Bank Group

Good Practice Note – IFC Life and Fire Safety: Hospitals | v

vi | Good Practice Note – IFC Life and Fire Safety: Hospitals
Introduction

The Life and Fire Safety (LFS) Good Practice Notes (GPNs) are technical reference documents developed for two
main purposes:1

• To support IFC’s investment decisions when evaluating if life and fire safety objectives have been achieved

• As a general guideline for the project team to develop a life and fire concept for the specific occupancy

This GPN is a guideline for investment projects in both new and existing occupancies.

The GPN provides further guidance to section 3.3 of the World Bank Group (WBG) General Environmental,
Health, and Safety (EHS) Guidelines, which are the core of IFC’s requirements on life and fire safety.

DOCUMENT STRUCTURE

This GPN consists of two main parts:

• A description of fire safety approach, specific requirements and components of fire protection

• Four annexes:
-- Annex A. Guideline Key Life and Fire Safety Design Principles
-- Annex B. Key Life and Fire Safety Audit Aspects
-- Annex C. Inspection and Maintenance Schedule
-- Annex D. Life and Fire Safety Documentation and Approval Flow

LIFE AND FIRE SAFETY OBJECTIVES

The following objectives should be demonstrated by the project team when designing a building:

• Initially use a defend in place strategy followed by safe evacuation of patients

• Limit fire and smoke spread to the room of fire origin

• Safe intervention for fire brigade

These life and fire safety objectives can only be achieved through implementation of technical and operational
measures.

1
This document is not a legal reference.

Good Practice Note – IFC Life and Fire Safety: Hospitals | 1

2 | Good Practice Note – IFC Life and Fire Safety: Hospitals
1. Health Care Occupancies-Specific Fire Risks

Patients in health care occupancies are one of the most vulnerable population groups in case of a fire. Unlike most
other buildings and occupancies, the least desirable emergency action in a health care occupancy is the wholesale
relocation or evacuation of patients who are often incapable of self-preservation due to age or physical or mental
disabilities.

Besides this vulnerability of the population, a health care occupancy houses some considerable fire hazards:

• Considerable amounts of bed linen.

• Laboratories and / or operating rooms, where considerable amounts of flammable liquids and / or gases can
be used. These areas often also contain very specific and expensive equipment.

• Presence of oxygen bottles and / or oxygen transport systems.

Without specific fire safety measures, a developing fire would spread faster than the required time to evacuate all
patients.

2. Life and Fire Safety Components

APPROACH – “DEFEND-IN-PLACE”

A “defend-in-place” strategy is required to obtain an acceptable fire safety level in health care occupancies. This
strategy includes nearly the entire gamut of systems available.

The defend-in-place strategy is implemented using a “total concept”

approach. This approach provides an assortment of features that
are deemed necessary to avoid the movement of patients to the
outside during a fire. Of course, those patients or residents who Patients in hospitals are
might be perilously close to the effects of the fire are given a range
one of the most vulnerable
of protection features, such as being moved to an adjacent safe
population groups in case
refuge area on the same floor.
of a fire.
Requirements for allowable building construction types, sprinklers,
alarm and detection systems, and staff training work in harmony to
help ensure that a patient can be safely and adequately protected,
regardless of where a fire starts.

Staff action is an integral part of the life safety features required

in a health care facility. The proper response from staff in terms of
availability, actions, and management of a fire can readily influence

Good Practice Note – IFC Life and Fire Safety: Hospitals | 3

the outcome of a fire. Health care facility staff are charged with the responsibility of preserving the safety of their
charges, whether that involves informing patients who are not in jeopardy from the fire or helping to relocate
those who are.

Staff training, coupled with the traditional built-in systems and features (e.g., construction; compartmentation;
interior finish; alarm, detection, and sprinkler systems; and control of contents and furnishings), combine to
provide a safe environment for one of the most vulnerable population groups.

Hence, the required level of life and fire safety can be achieved by implementing a range of fire safety measures.

A summary table of the key LFS design criteria is included in Annex A of this document. In the following paragraphs,
each of the key aspects is described in more detail.

STRUCTURAL FIRE RESISTANCE

GOALS

Since a ‘defend-in-place’ strategy is used, the building structure should be strong enough to withstand a fire in
the room of fire origin.

REQUIREMENTS

As a first requirement, the building structure should be non-combustible.

Other requirements of the building structure depend on the height of the building. The following values are
recommended:

• Single-story building: 60 minutes structural resistance

• All other buildings: 120 minutes structural resistance

These structural fire resistance requirements can be achieved by following materials:

• Columns and beams of reinforced concrete. Design of these elements should take into account static and
dynamic forces, fire resistance, etc.

• Metal columns and beams. Since metal loses its strength at elevated temperatures, these elements should be
protected by intumescent2 coatings or material insulation such as gypsum casings, etc. Another option is to
use concrete poured metal elements.

MAINTENANCE

Maintenance of fire resistant structures depends on the material used. Concrete elements don’t require specific
maintenance. Strength calculations need to be performed if higher loads are applied or if elements are altered.

Coatings are more vulnerable to damage and should be visually inspected regularly. Coatings need to be reapplied
at regular intervals, in accordance with maintenance instructions. Fire resistant casings might also be vulnerable
to damage and need to be visually inspected regularly.

2
Materials that swell when exposed to heat, providing insulating or sealing properties.

4 | Good Practice Note – IFC Life and Fire Safety: Hospitals

FIRE COMPARTMENTATION

COMPARTMENTATION GOALS

Well-maintained fire compartmentation confines fire and smoke to a limited area in the building. It is the
fundamental basis of passive fire protection. A fire compartment can contain single or multiple rooms. In health
care occupancies however, the first intent is to limit the fire spread to the room of fire origin.

Fire compartmentation enables three goals of fire protection:

• Life safety

• Property protection

• Continuity of operations

The following good practices are recommended:

• Every floor forms a single fire compartment

• Every occupancy type / function area forms a single fire compartment

• High-risk areas are located in separate fire compartments

• Safe means of egress are enclosed by fire-rated walls and doors

• Vertical openings (stairs, elevators, utility shafts) are

enclosed by fire-rated walls and doors Well-maintained fire
compartmentation confines fire
• Floors with patients contain the following barriers
and smoke to a limited area in
against fire and / or smoke movement:
the building
-- Barriers between all patient rooms
-- Barriers between patient rooms and corridors
-- Barriers separating each floor into at least two
compartments thus providing a safe refuge area

In the following sections, more guidance is given.

COMPARTMENTATION BETWEEN FLOORS

Fire compartmentation between floors prevents a fire from

spreading quickly between floors. The fire compartmentation
of the floor slab should have at least a fire resistance of:

• 1 hour for buildings not exceeding 25 m

• 2 hour for buildings exceeding 25 m

Attention should also be given to prevent possible flame

spread through the openings on the outside of the building.

Atria are required to be separated from all patient rooms

with at least a 1 hour fire separation. Evacuation of patients
through the atrium is not allowed.

Good Practice Note – IFC Life and Fire Safety: Hospitals | 5

COMPARTMENTATION BETWEEN OCCUPANCIES / FUNCTION AREAS

The following occupancies / function areas should form separate fire compartments, with a fire rating of at least
60 minutes:
• Patient room areas

• Kitchen and restaurant

• Laundry

• Surgery areas

• Laboratory areas

• Parking areas

• Soiled linens storage

• Electrical/mechanical areas

SAFE MEANS OF EGRESS

In order to protect people against toxic effects and heat impact of smoke resulting from a fire, only a limited
evacuation distance is allowed through which one can be exposed. After this evacuation distance, people should
be able to evacuate through safe means of egress to the outside. These means of egress are separated from the
rest of the building by walls and doors with sufficient fire rating.

On floors containing patient rooms, another level of protection is required: each floor should be subdivided into
at least two compartments. If a fire occurs, another compartment on the floor can act as a safe refuge for the
patients who were located in the compartment of fire origin.

VERTICAL OPENINGS

Vertical openings in floors are particularly hazardous because they enable rapid fire and smoke spread through
the building if they are not protected. As a general guideline, vertical openings should have a fire rating of at
least 2 hours.

ADDITIONAL BARRIERS IN PATIENT ROOM AREAS

Since it is the intent to limit the fire to the room of fire origin, the following additional fire compartmentation is
good practice:

• Between patient rooms: compartmentation at least smoke tight, preferably ½ hour flame tight

• Between patient rooms and corridors: compartmentation preferably ½ hour flame tight

• Safe refuge separations in patient room compartments: fire rating of at least 1 hour

COMPARTMENT CONSTRUCTION

A well-constructed fire compartment consists of walls that are strong enough to provide the required fire rating.
Openings in these walls can only be made if they are sealed by certified components. An overview of the most
important components is given in the following sections.

6 | Good Practice Note – IFC Life and Fire Safety: Hospitals

FIRE RATED DOORS

Fire rated doors should be always certified to have a defined fire rating. As a general guideline, the fire doors
should have the same fire rating as the fire walls. Exceptions are possible if national legislation accepts doors with
a lower fire rating than the walls (e.g., U.S. standards accept that doors have a fire rating which is approximately
2/3 of the wall’s fire rating).

The installer of the fire rated doors should follow the manufacturer’s published instructions, and should provide
for every door a certificate that the door is installed in accordance with these requirements.

FIRE RATED WINDOWS

Windows are possible in fire rated walls if they have a certified fire rating. The fire rating of the window should
be equal to the wall fire rating.

FIRE RATED DUCTWORK

When ducts are installed through fire walls, one of following options should be installed to protect the opening
against fire spread:

• The duct should be encased in a fire rated enclosure that has the same fire rating as the fire rated wall.

• A fire rated damper should be installed in the duct where it penetrates the fire rated wall. This fire rated
damper should have a certificate for the same fire rating as the fire rated wall. The opening between wall
and duct should be sealed with material having the same fire rating as the wall.

SEALING OF OPENINGS

All other openings (cables and cable trays, plastic or metal pipes) should be sealed with material that provides a
fire rating equal to the fire rating of the wall. If plastic pipes protrude through a fire rated wall, specific fire rated
collars should be installed in the penetration through the wall. It is recommended that a certificate is provided
for every specific penetration through a fire rated wall.

MAINTENANCE

Compartmentation as such doesn’t require much maintenance, since most of the protection measures are passive.
However the following items should be inspected annually:

• Fire doors:
-- If doors are self-closing, check if they still latch correctly and check for damage to the door
-- If doors should close upon fire detection: test the mechanism by activating a fire detector

• Fire dampers: inspect the closing mechanism

• Smoke dampers: test if the damper closes upon fire detection

The effectiveness of fire compartmentation to confine fire and smoke relies heavily on the protection of openings
through the fire rated wall/floors. A well-implemented ‘management of change’ program is necessary to identify
alterations that can have an impact on a fire compartment. It is often noticed that fire wall penetrations are not
properly sealed after modifications (e.g., additional penetration for cables), which can have an immense impact
on the performance of the fire rated wall.

Good Practice Note – IFC Life and Fire Safety: Hospitals | 7

INTERIOR FINISH

GOALS OF INTERIOR FINISH

The fire spread in a room is highly dependent on the flammability of wall, floor and ceiling materials. Flash-over
can be expected within minutes if the interior finish materials will contribute easily to the fire. Apart from the
flammability of the materials, other factors can also influence the hazard to the people close to the fire:

• Flame spread characteristics

• Amount of smoke produced by the burning material

• Toxicity of the smoke

• Tendency to create droplets when burning

The choice of interior finish materials will strongly influence life safety.

CHOICE OF INTERIOR FINISH MATERIALS

Since patients are particularly vulnerable to a fire, it is important to maximize the selection of materials that are
non-combustible or difficult to ignite.

Since standards of reaction to fire are hard to compare, it is difficult to define in this section requirements on class
of materials.

The following guidelines, however, can be given:

• Always permitted: concrete elements, gypsum finishes, ceramic materials, metal ceiling elements, rockwool
elements for false ceilings.

• Further investigation required: all common plastic materials, since these materials present a large variation
on flammability, smoke production and toxicity.

• Never allowed: low density fibreboard, wood-based panels, plastic based insulation products.

The requirements for interior finish can be reduced by the installation of a sprinkler system. As a general rule,
however, the ‘never allowed’ materials cannot even be permitted when sprinkler systems are installed.

MAINTENANCE

No specific requirements on maintenance exist.

A well implemented ‘management of change’ program is however necessary to identify which materials are to be
used during modification projects in the building.

FURNISHINGS, MATTRESSES, DECORATION

GOALS

Just as with interior finish materials, the room furnishing has a big impact on the potential spread of a fire. By
selecting proper materials, the hazard to people close to the fire can be significantly reduced. The choice of
furnishing, mattress type and decoration has most impact on life safety.

8 | Good Practice Note – IFC Life and Fire Safety: Hospitals

CHOICE OF FURNISHINGS, MATTRESSES AND DECORATION

Foam materials can contribute significantly to the strength of a fire. For this reason, it is recommended to avoid
as much as possible upholstered furniture in patient rooms. Specific standardized tests on performance of this
type of furniture in fires exist. If such furniture is selected, it is highly recommended to select certified items that
have a better performance in a fire.

Mattresses may also contain combustible foaming materials. As a minimum, these mattresses should pass tests
on their resistance against smouldering cigarettes or other small objects.

Curtains can also have a large impact on the fire spread, due to their vertical orientation. Attention should be
paid to the selection of fire retardant curtains that have a good reaction to fire.

MAINTENANCE

Also for this topic, a well-implemented ‘management of change’ program is necessary to identify which materials
are to be used during modification projects in the building.

Good Practice Note – IFC Life and Fire Safety: Hospitals | 9

FIRE DETECTION

GOALS OF FIRE DETECTION

Automatic fire detection systems provide a fast and reliable means to detect a fire in its incipient stage. As such,
they enable following goals of fire protection:

• Life safety

• Property protection

• Continuity of operations

In order to react as quickly as possible, the installation of an automatic smoke detection system is extremely
important in health care occupancies.

INSTALLATION OF FIRE DETECTION SYSTEMS

An automatic fire detection system consists of following components:

• A fire alarm control panel (FACP) that manages the complete system

• Fire detectors

• Manual alarm callpoints (MACs)

• Input / output modules (I/O modules) that integrate specific signals from / to equipment managed by the FACP

It is strongly recommended to only install fire detection systems that are accepted by national standards or
approved by accredited bodies. The design of the system should be performed by a company that is certified for
the installation of such systems.

A ‘cause and effect matrix’ should be developed during the design.

This matrix should summarize all actions that need to be activated
by the FACP upon fire detection in one of the detection zones.
Automatic fire detection
The FACP or one of its repeater panels should be located in a
systems provide a fast and
continuously staffed location.
reliable means to detect a
It is recommended to automatically transmit a confirmed fire alarm fire in its incipient stage.
signal to the fire department or to a dedicated command post in order
to initiate fire fighting intervention as soon as possible. Procedures
in which the alarm is verified by personnel before the alarm is
transmitted are permitted.

MAINTENANCE

Since a fire detection system is composed of often sensitive electronic

equipment, proper maintenance of the system is vital: the system
should be maintained annually by a certified company.

10 | Good Practice Note – IFC Life and Fire Safety: Hospitals

Besides this yearly maintenance, the system owner is responsible
for the daily follow-up of technical alarms. Equally important Alarm sounders should
is a ‘management of change’ procedure: with every change of be strategically installed
layout or function of any area, a verification should be performed in the building to obtain
that the detection system in the area is still capable to detect a distinctive alarm signal
a fire swiftly.
throughout.
FIRE ALARM

GOALS OF FIRE ALARM

The main goal of a fire alarm system is to start the evacuation

of a compartment or complete building in a timely and orderly
manner.

In order to meet this goal, the alarm signal should be:

• Clearly distinct from any other sound in the building
• Loud enough in all areas

Fire alarm signals can be roughly divided into following categories:

• Audible alarms (e.g., siren, bell)
• Voice evacuation systems
• Visible notification signals

A siren system can be installed in all health care areas that are
not accessible to patients: health care personnel should know the fire alarm signal and should know what to do
in case of fire alarm.

In patient areas, a voice evacuation system is preferred: this system combines a general alert system with pre-recorded
messages. With this system, specific directives can also be given for one alarm zone or for the complete building.

Visible notification are permitted to be used in lieu of audible devices in critical care areas. Visible devices should
be considered particularly in those areas where the risk of interference with medical equipment monitoring alarms
is highest.

INSTALLATION OF FIRE ALARM SYSTEMS

Alarm sounders should be strategically installed in the building to obtain a distinctive alarm signal throughout.
The following sound levels should be obtained:
• Surgery areas and other critical care areas: visible notification instead of audible signals.
• Other areas: at least 65 dBA or 15 dBA above the average ambient sound level, measured 1.5 m above
floor level.
• Voice messages are not required to meet the sound levels indicated above. The message should however be
intelligible within specific spaces in the building. These areas should be predetermined during the design
and should include minimally:
-- All large public areas as reception, waiting rooms, etc.
-- Patient room areas (common areas and corridors).

Good Practice Note – IFC Life and Fire Safety: Hospitals | 11

12 | Good Practice Note – IFC Life and Fire Safety: Hospitals
The maximum sound level in any location should not exceed 110 dBA. Visible notification means can be provided
in areas with potential high noise levels (e.g., generator rooms).

The fire alarm system should be divided into alarm zones in order to allow for a phased evacuation of the
building. Several fire compartments can be combined into one alarm zone, but it is not allowed to subdivide a
fire compartment into different alarm zones.

The fire alarm system is an installation that needs to remain in service during fire conditions: care should be taken
to install fire rated cabling and to supervise the correct working of all electronic equipment.

MAINTENANCE

The alarm system should be maintained annually by a certified company. The alarm should be tested at least
annually to check if sound levels comply.

During change projects, it should always be verified

that the sound levels are still attained in every area.

MEANS OF EGRESS
In order to protect people
EGRESS GOALS
against toxic effects and heat
The means of egress allow people to evacuate safely impact of smoke resulting from
from the health care facility or remain safely inside
a fire, only a limited evacuation
temporarily (defend-in-place). In order to achieve
distance is allowed.
this goal, the following requirements should be met:

• The path on which people can be exposed to fire

and smoke should be limited in distance.

• The means of egress should have sufficient width

to allow all occupants to evacuate in due time.

• Enough independent evacuation ways should be

available to allow a safe evacuation if one of the
routes is blocked by a fire.

• People are not impeded on the evacuation route

by blocked or locked doors, low ceiling heights,
too narrow routes, steep stairs, low illumination
levels, storage of materials, etc.

• People should be able to locate the exits easily.

• In patient room areas, people are often not capable

to evacuate without any assistance. Every floor
should therefore be divided into at least two safe
refuge areas with enough capacity to locate all
beds safely. Every safe refuge area on the floor
should be directly accessible by a fire service
access elevator that can be used to evacuate the
beds from the building if necessary.

Good Practice Note – IFC Life and Fire Safety: Hospitals | 13

DESIGN OF MEANS OF EGRESS

MAXIMUM EVACUATION LENGTHS

The evacuation route consists of a number of components for which definitions are given below:

• Common path: The portion of a route that must be traversed before separate and distinct paths of travel to
at least two exits are available.

• Exit: That portion of a means of egress that is separated from all other spaces of the building or structure by
construction, location, or equipment as required to provide a protected way of travel to the exit discharge.
Staircases or direct accesses to the outside are typical examples of exits. The entrance to a safe refuge area
in patient room areas is not considered to be an exit.

• Exit discharge: That portion of a means of egress between the termination of an exit and a public way.

• Dead-end corridor: That portion of an exit access corridor in which the travel to an exit is in one direction only.

Recommended maximal evacuation lengths can be found in Annex A.

The following other guidelines should be taken into account:

• Maximum 50 percent of the exit capacity is allowed to discharge through a lobby or reception area. All
other exit capacity should discharge directly to the outside.

• Main entrance requirements for areas with occupant loads that are higher than 50 persons (reception area,
waiting rooms, etc.)
-- The main entrance should be of a width that accommodates one-half of the total occupant load.
-- In any case, additional exits shall be provided for at least one-half of the occupant load.

ARRANGEMENT OF MEANS OF EGRESS

Enough means of egress should be available to allow people to evacuate safely if one of the exits cannot be
reached due to the fire. In general, it is recommended to organize evacuation routes in such a way that at least
two independent exits can be reached from every area in the building. A part of these exit routes can be ‘common
path,’ see Annex A for recommendations on maximum lengths.

The larger the maximum occupant load of an area, the more independent evacuation routes should be provided.

The means of egress should be organized in such a way that maximum one route can be blocked in case of a single
fire: exits, exit accesses and exit discharges shall be remotely located from each other. As a general guideline,
exits are considered to be remote from each other if the distance between the two exits is not less than one-half
of the length of the maximum overall diagonal dimension of the building or the area to be served. Moreover, it is
highly recommended that every safe refuge area in patient room areas gives access to at least two exits without
returning to the area of fire origin.

MEANS OF EGRESS COMPONENTS

People should be able to move quickly on means of egress: all components should be designed to enable a fluent
evacuation. The following recommendations are given:

• As a general recommendation, evacuation doors should never be provided with locks. People should always
be able to evacuate through emergency doors if necessary. All doors should be able to be opened without

14 | Good Practice Note – IFC Life and Fire Safety: Hospitals

 excessive force. If locks are necessary due to the patient’s conditions, enough staff should be available at
all times to unlock the doors and direct patients to safe areas, or must utilize special locking arrangements
(delay locks, exit push buttons, etc.).

• Exits and exit accesses should be well illuminated: people should be able to see all possible obstructions and
dangerous components such as turns in corridors, junctions, stair treads, ramps, etc.

In patient room areas, enough space should be provided in every safe refuge area to locate the beds from a
compartment where a fire starts. If this space is located in corridors, these should be wide enough to enable
further evacuation to elevators, etc.

Good Practice Note – IFC Life and Fire Safety: Hospitals | 15

SIGNAGE

All exits should be well marked: signage should be provided above the exit doors and directional signs should be
installed judiciously throughout the building. The signs should be illuminated by dedicated emergency lighting.

MAINTENANCE

Regular inspection rounds are needed to check that all means of egress are free and unobstructed. These inspections
can be performed by the security teams or during so-called ‘self-inspection’ rounds on which this and other fire
safety aspects are checked. Formalized records should be kept on the findings of the rounds and the actions that
were taken as a result of the inspections.

The emergency lighting requires at least yearly maintenance by a certified company. During these maintenance
rounds, the performance of system batteries should be checked. Other failures like broken bulbs should be
corrected as soon as possible.

16 | Good Practice Note – IFC Life and Fire Safety: Hospitals

FIRE CONTROL AND SUPPRESSION

GOALS OF FIRE SUPPRESSION

The objective of a fire suppression system is to control or extinguish the fire in its early stage. These means of suppression
can be manual (fire extinguishers, hose reels) or automatic (sprinkler systems, gas extinguishing systems, etc.). The
primary goal of these suppression means is to limit property damage and to control the fire before it becomes
hazardous to people not close to the fire or to intervention teams. Due to the vulnerability of the patients, the
system should be part of a strategy to keep the fire in the room of fire origin.

FIRE EXTINGUISHERS

Fire extinguishers are active fire protection devices used to extinguish or control small fires. They are intended to
be used by the hospital’s first intervention team or by visitors that have the expertise to use them. They are not
intended for use on an out-of-control fire that can endanger the user.

Many types of fire extinguishers are available: water, foam, dry chemical, carbon dioxide, etc. All of them have
specific advantages and disadvantages and should be selected by experienced persons.

At a minimum, fire extinguishers are required in hazardous areas of unsprinklered buildings, but are recommended
to be installed throughout the hospital building. In any case, the position of fire extinguishers should comply
with local code requirements.

STANDPIPE SYSTEM

A standpipe systems is a type of rigid water piping that is built in multi-story buildings to which fire hoses can
be connected. The presence of standpipe systems saves time for firefighters: laying a firehose up a stairwell takes
considerable time.

Good Practice Note – IFC Life and Fire Safety: Hospitals | 17

Two types of standpipe systems are available:

• Wet standpipe systems, that are filled with water and are pressurized at all times. Often, hoses are already
connected to the system, which allows the fire department to quickly attack the fire. Wet standpipe systems
can be combined with sprinkler systems by connecting them to the same piping network.

• Dry standpipe systems, that are empty at normal conditions and need to be connected to a fire hydrant (or
other water source) in case of an intervention.

Wet standpipe systems are recommended in both sprinklered and unsprinklered buildings, because they provide
a means of suppression that is readily available and less restricted than fire extinguishers.

Dry standpipe systems are particularly recommended in buildings higher than 4 floors without a wet standpipe
system. Both systems are best installed in staircases, since these form a relatively safe location for the fire department
to prepare an attack of the fire.

Apart from the two standpipe systems described above, hose reel cabinets can be installed throughout the building
and connected to the sprinkler system or directly to the water distribution system. These hoses work on a lower
pressure which allows them to be used by first intervention teams or occupants. Hose reel cabinets are only suitable
for smaller fires, since water flows are considerably lower than the systems described above.

AUTOMATIC SUPPRESSION

If well-designed and maintained, automatic sprinkler systems are considered to be the most effective and reliable
fire suppression system available. Statistical information shows that approximately 95% of fires are confined
to the room of origin when a sprinkler system is installed. For this reason, sprinkler systems are required in all
hospital buildings, except low-rise buildings that only contain outpatient rooms.

Sprinkler systems should be designed in accordance with approved standards. Sprinkler installation design is based
on minimum spray densities over a maximum area of operation. The higher the risk classification of the rooms,
the higher the requirements will be for the spray densities and the area of operation. The water supply should be
reliable: it is recommended to install a dedicated fire water tank and a fire pump certified by an accredited body.
The fire pump should have a reliable power source: an electric driven pump should be connected to an emergency
generator, or an engine driven fire pump should be installed instead. Furthermore, the installation of valves in the
system should be limited to the strict minimum to operate the system: statistics show that most sprinkler systems
fail due to a closed valve.

In hospitals, discussions often arise on sprinkler protection of surgery rooms and rooms with expensive medical
equipment. The following arguments are in favor the use of sprinklers:

• Sprinkler systems are highly reliable. Should unwanted activation be a concern, a pre-action system can
further decrease the potential of unwanted activation of a sprinkler head.

• Sprinklers only activate at a temperature of minimum 68°C. One can expect that, if the room is occupied
when the fire ignites, the personnel has suppressed the fire before the sprinklers activate. The sprinkler system
can be seen as a system that will control larger fires.

• Most fires are normally controlled by two sprinklers, not all sprinklers in the room / compartment will be
activated at once. Water damage will therefore only occur near the fire origin.

18 | Good Practice Note – IFC Life and Fire Safety: Hospitals

If there are further objections or even legal restraints against the installation of sprinkler systems in these rooms,
the area should be well separated from the remainder of the hospital. Besides the systems mentioned above, other
systems are available to protect specific rooms:

• Automatic gas extinguishing systems are suitable to protect vulnerable spaces that are susceptible to water
damage. These systems are commonly used in server rooms or in electrical rooms. It is advised to install such
a system if a fire in the room can lead to a large business interruption or a high value loss. The systems are
however less suitable for the protection of areas that are normally occupied by patients or hospital personnel.

• Kitchen hood systems are designed to extinguish cooking fires caused by grease or grease-laden vapors.
The suppression agent consists of a wet chemical or a water mist.

MAINTENANCE

Proper maintenance of fire extinguishers, fire hoses and all mechanical parts of automatic suppression system is
needed to ensure proper performance. Maintenance should be performed at least annually by a certified company.

Besides this yearly maintenance, the system owner is responsible for some general maintenance tasks and regular
checks. Equally important is a ‘management of change’ procedure: every change of layout or function of any area,
requires verification that the suppression system in the area is still capable to control or suppress a fire effectively.

SMOKE CONTROL

GOALS OF SMOKE CONTROL

Smoke control systems are designed to control the area affected by smoke, to limit the smoke temperature or to
provide smoke-free zones in egress routes. As such, they enable following goals of fire protection:

• Life safety

• Property protection

Smoke control can be performed by passive means (smoke barriers or smoke curtains) and / or active systems.
Active systems consist of natural ventilation, mechanical smoke extraction, or smoke pressurization systems.

In hospitals, the following systems are regularly used:

• Smoke and Heat Exhaust Ventilation Systems (SHEVS) in atria or large compartments

• Corridor smoke removal systems in guestroom corridors

• Pressurization systems in stairwells and / or elevator shafts or lobbies

SMOKE AND HEAT EXHAUST VENTILATION SYSTEMS (SHEVS)

SHEVS are designed to limit the smoke spread to a certain area (‘smoke control zone’), to obtain a smoke-free
height in the smoke control zone and to limit the smoke temperature.

SHEVS are typically installed in atria: the open connections between floors are extremely vulnerable to rapid
smoke spread. This creates very hazardous situations and occupants can be surprised by toxic fumes.

Good Practice Note – IFC Life and Fire Safety: Hospitals | 19

20 | Good Practice Note – IFC Life and Fire Safety: Hospitals
A SHEVS’ design is based on a design fire that can be obtained from specific standards. Based on the design fire
and the required smoke-free height, calculations can be performed to estimate the required mechanical extraction
rate or the required amount of ventilation openings.

Equally important to the extraction rate is to provide enough supply air to the area: without this fresh supply air,
the system will not be able to extract smoke from the smoke control area.

Since SHEVS extract hot air from the smoke control area, the system can delay sprinkler activation. Attention
should be paid to this interaction if both systems are combined in the same area. In general, it is good practice
to activate the SHEVS by a sprinkler flow alarm.

CORRIDOR SMOKE REMOVAL SYSTEM

Corridor smoke removal systems are fairly basic systems in which a fixed number of air changes is imposed in
corridors. A corridor smoke removal system creates safer egress routes, due to the constant supply of fresh air
which dilutes smoke that enters the corridor. Corridor smoke removal systems are often required by local codes.

STAIRWELL AND ELEVATOR SHAFT PRESSURIZATION SYSTEMS

Pressurization systems impede smoke spread to certain areas of the building by creating an overpressure. They
are commonly used and highly recommended in staircases in high-rise buildings, since they provide an extra grade
of protection that allows for longer evacuation times.

Pressurization systems in staircases should be carefully designed: they should create a pressure difference of at least
50 Pa (all doors closed) and an airflow of at least 0.75 m.s-1 through an open door. On the other hand, it should
still be possible to open the staircase doors easily (most codes prescribe a maximum opening force of 100 N).
Pressurization systems can also be installed to protect elevator shafts against vertical smoke spread.

MAINTENANCE

Proper maintenance of all mechanical parts of the system is needed to ensure proper performance of the system.
Maintenance should be performed at least yearly by a certified company (preferably the installer of the system).

PROTECTION FROM FIRE HAZARDS

GOAL

Certain areas in health care buildings typically contain a higher fire risk than most of the other areas. Typical
examples of these areas are:

• Areas used for storage of combustibles or flammables:

-- Flammable liquid rooms (storage of solvents, etc.)
-- Large archives
-- Trash collection rooms
-- Linen rooms
-- Oxygen storage and generation facilities
-- Medical gases

Good Practice Note – IFC Life and Fire Safety: Hospitals | 21

22 | Good Practice Note – IFC Life and Fire Safety: Hospitals
 • Areas housing heat-producing appliances:
-- Boiler rooms
-- Generator rooms
-- Kitchens
-- Laundries
-- Incinerator rooms
-- Autoclave rooms

• Areas used for maintenance purposes:

-- Workshops

• Areas containing a higher fire load:

-- Employee locker rooms
-- Laboratories
-- Gift shops (larger than 50 m2)
-- Car parking areas

Due to the higher risk, these areas should be well segregated from the other hospital areas and / or protected by
dedicated fire suppression systems. Examples of such fire suppression systems are wet chemical systems in kitchen
hoods, powder extinguishing systems protecting gasoline burners in boiler rooms, gas extinguishing systems on
power generators, etc.

A proper separation of the fire hazards enables following goals of fire protection:

• Property protection

• Business continuity

DESIGN OF FIRE HAZARD PROTECTION

Protection from fire hazards can be done by separating the area from the remainder of the hospital with fire rated
walls, by active fire suppression systems or a combination of both. The required fire rating depends on the fire
load and/or potential ignition sources in the area, but following ratings can be used as a guideline:

• 2 hour fire rating: flammable liquid rooms, laboratories involving considerable amounts of flammable liquids,
boiler and generator rooms, transformer rooms with oil-filled transformers.

• 1 hour fire rating: large archives, trash collection rooms, laundries, linen rooms, kitchens, workshops, employee
locker rooms and gift shops, high-tension areas and transformer rooms.

The installation of active suppression systems can lead to a reduction of the recommended values above.

MAINTENANCE

As for other active and passive systems, regular maintenance is needed. We refer to the chapters above for the
recommendations.

Good Practice Note – IFC Life and Fire Safety: Hospitals | 23

24 | Good Practice Note – IFC Life and Fire Safety: Hospitals
3. Documentation

This section describes documentation that should be developed during the design, construction and exploitation
of the hospital.

FIRE SAFETY MASTER PLAN

The fire safety master plan describes on a conceptual basis all the life and fire safety aspects that are integrated
in the building.

The document should include all major fire risks, applicable codes, standards and regulations, and mitigation
measures. The master plan will be prepared by a suitably qualified professional acceptable to IFC.

It should cover following aspects:

• Fire prevention

• Means of egress

• Detection and alarm systems

• Compartmentation

• Fire suppression and control

• Emergency response plan

• Operation and maintenance

The fire safety master plan should be updated during the building’s lifetime: after every significant modification,
alterations should be checked against the plan and additional life and fire safety measures should be taken if
necessary.

FIRE SAFETY DESIGN DOCUMENTATION

The fire safety design documentation provides more detailed information on the systems installed in the building:
it typically contains following information:

• As-built plans of the systems

• Verification calculations if required

• Data sheets of all components

• List of necessary spare parts

• Supplier list

• System certificates

• Fire safety design documentation

Good Practice Note – IFC Life and Fire Safety: Hospitals | 25

FIRE PREVENTION PROGRAM

The fire prevention program typically describes the staff responsibilities to prevent a fire. It should also include
a training program for staff.

MANAGEMENT OF CHANGE PROGRAM

An effective Management of Change Program consists of procedures that consider:

• The basis for the proposed change

• The impact of the change on safety and health of employees and guests

• Necessary modifications on operating and emergency procedures

• Required authorization of the proposed changes

Each of these aspects should be formalized in a plan that demonstrates that the LFS level of the hospital is at least
maintained throughout the change.

EMERGENCY RESPONSE PLANS

The emergency response plan describes the staff responsibilities in case of a fire or other type of emergency.

Health care occupants have, in large part, varied degrees of physical disability, and their removal to the outside
is impractical in many cases, except as a last resort.

Since patients are very vulnerable to the consequences of a fire, the emergency response plan should first focus on
the evacuation of patients away from the fire origin. After this first evacuation, evaluations should be performed
to determine the need to further evacuate the other compartments of the hospital.

26 | Good Practice Note – IFC Life and Fire Safety: Hospitals

The emergency response plan should at least contain following topics (see additional information in WBG EHS
Guidelines):

• Use of alarms

• Transmission of alarms to fire department

• Emergency phone call to fire department

• Response to alarms

• Isolation of fire

• Evacuation of immediate area

• Evacuation of safe refuge area

• Preparation of floors and building for evacuation

• Extinguishment of fire

MAINTENANCE PLAN AND CONTRACT FOR ALL FIRE PROTECTION SYSTEMS

Fire protection systems require maintenance by qualified persons. A maintenance plan should be available, that
shows what systems are maintained with a certain frequency.

The plan should include checklists with the tasks done in-house (e.g., a fire pump needs to run +/- 15 min per
week) and the tasks done by maintenance contractors.

Maintenance contracts should be available for all tasks done by external parties.

TEST PLANS FOR ALL FIRE PROTECTION SYSTEMS

Apart from the maintenance, the systems should be tested on a regular basis. Typically, these tasks can be performed
in-house without the support of a maintenance contractor.

Test plans should include checklists with the tasks performed and their frequency. All test activities should be logged.

INCIDENT REPORTING DOCUMENTS

Incident reporting documents enable an organization to analyse incidents and remediate.

They should contain at least:

• Event details: time, location, consequences

• Event analysis:
-- Was the event caused by an unsafe act or unsafe condition?
-- Could the incident be avoided?
-- Are additional safety measures necessary to avoid similar incidents?

Good Practice Note – IFC Life and Fire Safety: Hospitals | 27

4. Fire Safety Project Approaches

There are different approaches to demonstrate compliance with the requirements of the LFS section (section 3.3) of
the WBG EHS General Guidelines. Complying with local life and fire safety regulations is a minimum requirement
to be eligible for IFC investment.

Compliance with local regulations and with an internationally accepted level of life and fire safety should be
demonstrated by one of following approaches:

• Compliance with prescriptive codes in line with the WBG General EHS Guidelines.

• Performance based design: this alternative approach sets clear performance objectives by all stakeholders with
regard to life and fire safety. It uses specific methods and techniques often supported by computer modelling
to demonstrate that a health care building with certain defined fire safety measures is safe to operate.

5. Project Approval

For new developments, IFC will require an audit during following project phases:

• Finalization of Fire Safety Masterplan

• Finalization of Fire Protection Design

• Final testing and commissioning of fire protection systems

• Final Delivery Life and Fire Safety Documents

For existing properties, approval of the fire protection measures will be based on a technical due diligence:

• Verification of all available fire safety documentation

• Review of the hospital fire safety aspects, based on IFC GPN, WBG EHS Guidelines and codes of good practice

28 | Good Practice Note – IFC Life and Fire Safety: Hospitals

Good Practice Note – IFC Life and Fire Safety: Hospitals | 29
Annex A. Guideline Key Life and Fire Safety Design Principles

STRUCTURAL RESISTANCE
Recommended Single-story: 60 min > 1 story: 120 min

COMPARTMENTATION
Required Between building floors < 25 m: 60 min
Vertical openings > 25 m: 120 min
self-closing doors
Required Between function areas 60 min, self-closing doors
Safe means of egress
Required Corridors in patient room areas 30 min flame tight, self-closing doors
Required “Safe refuge” on patient floors 60 min, self-closing doors
Required High-risk areas Rating dependent on hazardous area and active
protection, self-closing doors

INTERIOR FINISH / FURNISHING, MATTRESSES, CURTAINS

Required As a minimum, all materials should comply with local regulations
Required Non-combustible interior finish materials, use of items that are tested on their performance in a fire.

FIRE DETECTION
Required Patient rooms: addressable fire detectors
Indication of the location of the fire in the nurse department on the floor
Required Throughout the building
Indicative price range(1):
New: 25 – 45 USD/m2
Existing: 30 – 50 USD/m2

FIRE ALARM
Required Alarm throughout buildings
Required Flashing lights in areas with high noise levels
Recommended Voice evacuation system in public areas and patient room areas
Recommended Flashing lights in surgery and other critical care areas

MEANS OF EGRESS
Required maximum evacuation lengths in sprinklered occupancies
Occupancy Common path Dead-end corridor Distance to exit Distance in patient room
Patient room areas 30 m 10 m 60 m 15 m
Restaurant 5 m 5 m 75 m
Commercial
Waiting area
Offices 30 m 15 m 90 m

30 | Good Practice Note – IFC Life and Fire Safety: Hospitals

MEANS OF EGRESS
Required maximum evacuation lengths in unsprinklered occupancies
Occupancy Common path Dead-end corridor Distance to exit Distance in patient room
Patient room areas 10 m 10 m 45 m 15 m
Restaurant 5 m 5 m 60 m
Commercial
Waiting area
Offices 25 m 5 m 60 m

Required Minimum 2 separate and independent exits per area(2)

Minimum 3 exits if 500 < # persons ≤ 1000
Minimum 4 exits if 1000 < # persons
Required Each safe refuge area in patient room areas has direct access to a fire access elevator
Every safe refuge area leads to two independent exits without returning to the area of fire origin.
Required Evacuation widths as per local codes.
Required Minimum 50% of exit capacity to discharge through safe means of egress, not leading through
the reception area.

FIRE EXTINGUISHERS
Required Hazardous areas of unsprinklered buildings
Recommended Throughout the buildings (as per local codes)

STANDPIPES
Recommended Wet standpipes and/or standpipes as per local codes
Hose reels throughout the building

AUTOMATIC SUPPRESSION SYSTEMS

Required Kitchen hood systems protecting hazardous cooking equipment (e.g., fat fryers) in open kitchens
Required Sprinkler systems throughout the building, except in low-rise hospitals that only contain outpatient
rooms.
Indicative price range(1):
New: 40 – 65 USD/m2
Existing: 55 – 80 USD/m2
Recommended Kitchen hood systems in kitchen areas that are separated from restaurants
Recommended Gas extinguishing systems in area where a fire can lead to large business interruption (eg computer
rooms, large archives)

SMOKE CONTROL
Required Stairwell pressurization system in buildings > 25 m
Required SHEVS in atria
Recommended Smoke removal system in guest room corridors, as per local code

(1): The indicative price ranges are general estimates that are considered to be representative for typical hospital buildings. Further variance might occur,
due to complexity of the building and regional price differences.

(2): Separate exits so that if one exit is blocked during an emergency the other is available for evacuation (a good practice is a distance of minimum 30 m
between exits or exits separated more than 1/2 maximum overall diagonal dimension of the building or area).

Good Practice Note – IFC Life and Fire Safety: Hospitals | 31

Annex B. Key Life and Fire Safety Audit Aspects
OVERALL FIRE SAFETY

Is a LFS master plan available?

Is the building accepted by local authorities? Are acceptance documents available?

FIRE COMPARTMENTATION

Are as-built compartmentation plans, showing all fire separations, available?

Are certificates for all components of fire separations available?

• Fire doors

• Fire dampers

• Cable, pipe and duct sealing materials

Is the actual fire compartmentation in line with what is indicated on the plans?

• Are certified fire doors installed in fire separation walls?

-- Are any fire doors blocked open?
-- Do door closers work properly?

• Are any unprotected openings visible?

INTERIOR FINISH / FURNISHING, MATTRESSES, CURTAINS

Are certificates available on the reaction of these materials to a fire?

EVACUATION

Are evacuation plans available?

• In the as-built file of the hospital

• On strategic locations in the building

Are all evacuation routes clearly marked?

• Are enough signs installed to show the evacuation routes?

• Is enough emergency light installed?

-- Are all evacuation pictograms illuminated?
-- Are evacuation routes well illuminated?
-- Is the emergency light system designed for a duration of 1 hour at least?
-- Is a meeting point clearly marked on a safe location outside the building?

32 | Good Practice Note – IFC Life and Fire Safety: Hospitals

Can the evacuation routes be used at all times?

• Are all evacuation doors free from locks?

• Are any evacuation doors blocked?

• Are all corridors, passages and stairs free from obstructions?

• Does at least 50% of the exit capacity discharge to the outside through safe means of egress, not leading
through lobby or reception areas (ground floor)?

FIRE DETECTION AND ALARM

Is all fire detection and alarm system information available?

• Fire detection plans, single-line diagrams

• Datasheets of all components

• Calculations (voltage drop calculations, battery capacity)

• Cause and effect matrix

• Testing and commissioning documents

• System logbook

Is the fire detection and alarm system installation approved by an independent body?

Is the actual fire detection and alarm system in line with what is indicated in the system information?

• Are tests in conformity with what is shown on the cause and effect matrix?

• Is the fire alarm signal easily notifiable?

-- Is the alarm signal loud enough and distinct from other signals?
-- Are additional flashing lights foreseen in areas with high noise levels?
-- Are flashing lights foreseen in rooms where there is a risk of interference between the fire alarm signal
and medical equipment monitoring signals?

Is the actual fire detection and alarm system fully operational?

• Is the fire alarm control panel free from technical faults?

• Are maintenance reports available and are all issues indicated on the reports resolved?

AUTOMATIC FIRE SUPPRESSION / SMOKE CONTROL

Is all information on automatic suppression / smoke control systems available?

• As-built installation plans

• Datasheets of all components

• Calculations (flow calculations, required capacity)

• Testing and commissioning documents

Good Practice Note – IFC Life and Fire Safety: Hospitals | 33

Is the automatic fire suppression / smoke control system approved by an independent body?

Is the actual system fully operational?

• Do any technical errors appear on the control panel?

• Are maintenance reports available and are all issues indicated on the reports resolved?

FIRE EXTINGUISHERS / HOSE REELS

Are plans available showing the location of all fire extinguishers and hose reels?

• In the as-built file of the hospital

• On the evacuation plans

Are all fire extinguishers and hose reels clearly marked?

• Are signs installed to show their location?

• Is emergency light installed to illuminate the signs?

Can the fire extinguishers / hose reels be used at all times?

• Is access free of locks?

• Are any fire extinguishers / hose reels blocked?

Are maintenance reports available and are all issues indicated on the reports resolved?

STANDPIPES

Are standpipes installed as indicated in the fire safety master plan and/or building permit?

Are the fire department connections at the base of the riser and in the building free from obstructions?

FIRE PREVENTION

Are good housekeeping rules applied and are they well followed?

Are formalized permit procedures applied for hot works and other activities that create a higher fire risk?

Is every employee aware of the fire risks related to his job and how to mitigate the consequences of a fire incident
(e.g., are nurses aware of the importance of good housekeeping, unobstructed routes in corridors, use of fire
resistant doors, etc.)?

Is a formal inspection procedure applied for life and fire safety aspects?

EMERGENCY RESPONSE

Is a formalized emergency response plan available?

Is the following information included in the emergency response plan:

• Use of alarms

34 | Good Practice Note – IFC Life and Fire Safety: Hospitals

 • Transmission of alarms to fire department

• Emergency phone call to fire department

• Response to alarms

• Isolation of fire

• Evacuation of immediate area

• Evacuation of safe refuge area

• Preparation of floors and building for evacuation

• Extinguishment of fire

Is every employee informed on how to react in case of a fire alarm? Do the employees receive regularly an update
of these procedures?

Are at all times enough employees available that are skilled in a first response to a fire alarm?

• Inspection of a fire alarm

• Activation of fire alarm

• Communication with local fire department

Are at all times enough employees available that are skilled in the use of fire extinguishers?

• Is the training of fire extinguishers repeated regularly?

Are at all times enough employees available that are skilled in the evacuation of patients?

• Is the evacuation training repeated regularly?

Are evacuation drills practiced at least once a year?

Good Practice Note – IFC Life and Fire Safety: Hospitals | 35

Annex C. Inspection and Maintenance Schedule

Frequency Automatic Standpipes Fire pump Water tank Kitchen hood Emergency
sprinkler suppression standby power
systems systems systems
WEEKLY Record Visual Check pump Check heating Inspect the
pressure inspection of house heating system during generator and its
dry standpipe freezing components
control valves weather
Record Fire pump Check water Check the
pressure of wet operating test level house-keeping
standpipes in the generator
room
Check packing Generator
gland tightness operation test
Check suction
and discharge
pressure
gauges
Check position
of valves
Control alarms
function
properly
MONTHLY Visual Visual Remove battery Check water Visual Inspect and
inspection of inspection of corrosion, clean temperature inspection of check the fan
section valves wet standpipe and dry battery system and alternator
and alarm control valves case belts
valves
Check battery Inspect the
charger and battery charger
charger rate and charger rate
Equalize Inspect and
charge in check the circuit
battery system breaker and
fuses
Exercise Inspect and test
isolation switch the governor oil
and circuit level and linkage
breaker
Inspect, clean Test each battery
and test circuit powered unit for
breakers 30 seconds
Operate the
transfer switch

By building owner.

By maintenance contractor.

Certification by accredited body as per legal requirements. Legal requirements prevail if they are more stringent. If certification is not
legally required, it should be done by third party accepted by IFC.

36 | Good Practice Note – IFC Life and Fire Safety: Hospitals

Frequency Automatic Standpipes Fire pump Water tank Kitchen hood Emergency
sprinkler suppression standby power
systems systems systems
QUARTERLY Test sprinkler Visual Check Visual Inspect the
flow and inspection of crankcase inspection of crankcase
pressure hoses and fire breather on tank breather
alarms department diesel pump
connections for proper
operation
Verify that fire Visual Clean water Inspect the
department inspection of strainer in exhaust system
connections pictograms cooling system insulation
are visible and for diesel fire
accessible pump
Test flow Check exhaust
switches system
insulation
for integrity
and check
exhaust system
clearance to
combustibles
to prevent fire
hazard.
Check battery
terminals to
ensure they
are clean and
thight.
SEMI- Test quick- Test tamper Check Check water Check all Test the
ANNUALLY opening switches operation of level alarms components antifreeze
devices and safety devices protection level
accelerators and alarms
of dry pipe
systems.
Test fire Verify that Test the
detection hazard has not operation of
system for changed safeties and
preaction alarms
and deluge
systems.
Test tamper Test emergency
switches generators
greater than
600 V under full
load
ANNUALLY Visual Visual Conduct Check Replace fusible Inspect and test
inspection of inspection of fire pump accessibility links tank vents and
sprinklers, piping performance and condition of overflow piping
piping, hangers test fire department for obstructions
connection
Check anti- Check nozzles Verify setting of Inspect fuel
freeze solution relief valve piping
of glycol
systems.

By building owner.

By maintenance contractor.

Certification by accredited body as per legal requirements. Legal requirements prevail if they are more stringent. If certification is not
legally required, it should be done by third party accepted by IFC.

Good Practice Note – IFC Life and Fire Safety: Hospitals | 37

 Frequency Automatic Standpipes Fire pump Water tank Kitchen hood Emergency
sprinkler systems suppression standby power
systems systems
Maintenance of Lubrication of Lubrication of Inspect and test
valves swing-out racks various parts louver motor and
controls
Cleaning of Reracking of Replace oil Inspect exhaust
strainers hoses and oil filters if system hangers
needed and supports and
test for excessive
back pressure
Functional test of Calibrate Inspect transfer
sprinkler system. pressure switch switch main
settings and contacts and
check accuracy exercise the
of pressure circuit breakers
sensors
Inspect fuel Check and test
piping the ignition
system of the
engine and test
injection pump
and injectors
Measure and
record resistance
readings with
insulation tester
Test each battery
powered unit
for its required
autonomy
Test the
emergency
generator under
full load or under
bank-load full test
Replace oil
and oil filters if
needed
EVERY 5 Internal inspection Inspection of
YEARS of check and tank interior
alarm valves
Calibrate pressure Check all
gauges valves
Certification Every year Every year Every year Every year
inspection by
third party

MONTHLY Visual inspection Verify that no

of panels (no alterations have
technical faults). been made to
the room
Doors are self-
closing or close
automatically
in case of
suppression

By building owner.

By maintenance contractor.

Certification by ACCREDITED body as per legal requirements. Legal requirements prevail if they are more stringent. If certification is
not legally required, it should be done by third party accepted by IFC.

38 | Good Practice Note – IFC Life and Fire Safety: Hospitals

Frequency Fire detection Gaseous Portable fire Fire doors Fire dampers Smoke
and alarm extinguishing extinguishers control
system system
QUARTERLY Visual inspection Visual Visual inspection
of system inspection of of doors
(callpoints not accessibility
blocked, free
space around
detectors, …)
Verify that doors
are not blocked
open
SEMI- Visual Functional
ANNUALLY inspection of test
system and
containers
Record
container
pressures and
weights
ANNUALLY Functional test Visual Maintain and Check door for Visual
of all detectors, inspection of recharge as physical damage, inspection of
call points and hoses required by no open holes hinges and
alarms maintenance left from replaced other moving
instruction hardware. parts
Functional Inspect Check door Remove
test of alarm enclosures closers on fusible link and
transmission or rooms for functionality and operate damper
tightness coordination of
door leaves at
double doors
Battery test Check closing Lubrication
of automatically as per
closing doors manufacturer’s
upon fire instructions
detection
Inspection of log
book
EVERY 5 Revision of Hydrostatic test
all detectors of system
YEARS
(without self-
check option)
Complete visual
inspection of
gas containers
EVERY 8 Revision of all
smoke detectors
YEARS
with self-check
option
Certification Every year Every year Every year
inspection by
third party

By building owner

By maintenance contractor

Certification by ACCREDITED body as per legal requirements. Legal requirements prevail if they are more stringent. If certification is
not legally required, it should be done by third party accepted by IFC.

Good Practice Note – IFC Life and Fire Safety: Hospitals | 39

 Annex D. Life and Fire Safety Documentation and Approval Flow
LFS DOCUMENTATION & APPROVAL FLOW FOR IFC PROJECTS
PHASE IFC REQUIREMENTS DOCUMENTATION IFC APPROVAL
CONCEPT DESIGN
WBG General EHS LFS Good Practice
LFS Cornerstones Guidelines Note

Prescriptive vs performance
based LFS Masterplan in
LFS Masterplan
accordance with IFC
Definition of design and Guidelines?
Local Legislation
installation codes

DETAILED DESIGN LFS Masterplan and

Detailed design
Int. Accepted LFS Detailed Design certified by LFS
Local LFS Codes
Detailed design Codes Documents

40 | Good Practice Note – IFC Life and Fire Safety: Hospitals

specialist?

Installation according
INSTALLATION to LFS Masterplan?

Construction Int. Accepted LFS LFS Good Practice Construction Certificates of System test results in
Codes Note Documents installation accordance with
Testing & Commissioning codes?

OPERATION
LFS Good Practice Maintenance “Due diligence”:
Int. Accepted Codes Emergency plan
Note records Design in accordance
Maintenance with codes of good
practice?
Management of change Inspection and tests of
existing systems?
Housekeeping Maintenance Fire prevention Incident reporting
Issues identified
manuals program documents
during supervision by
Emergency preparedness E&S specialist?

Footnote: all projects are expected to meet local fire safety requirements
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42 | Good Practice Note – IFC Life and Fire Safety: Hospitals