1 NYP BEST PRACTICES CODE REVIEW: LIFE SAFETY Larry Borsinger, MBA Director, Facilities Operations - Regulatory Compliance Sukhjit Tom Singh, MHA, MPH Field Director, Facilities Operations - Regulatory Compliance

2 Hartford Hospital Fire

3 NYP Eye Institute 5/18/2009

4 NYP Regulatory Portfolio Profile Basic Building Information Total # Buildings: 48 Total Square Feet: 7.6 M Total Beds: 2,331

5 Background & Significance Safety: – Vast majority of in-patients are incapable of self-preservation and rely on the building features/systems to protect them from the risks of fire & smoke. Regulatory: – Hospitals must be designed to protect patients, staff and visitors. – Requirements are driven by various agencies: Centers for Medicare & Medicaid Services (CMS) New York State Department of Health (DOH) The Joint Commission (TJC) Fire Department of New York/White Plains Department of Buildings (DOB) Occupational Safety & Health Administration (OSHA)

6 We Put Patients First 1.Establish Roles/Responsibilities 2.Define which projects require a life safety code analysis 3.Describe the various life safety elements beyond the typical project envelope 4.Review the process to prepare and submit life safety plans to NYP 5.Understand the importance of delivering a code compliant facility Objectives

7 We Put Patients First PM (FD&C) PM (FD&C) Facilities Operations Regulatory Compliance Facilities Operations Regulatory Compliance ORPPD Stonehill Taylor Architects A/E Team CM/GC Roles/Responsibilities

8 We Put Patients First Facilities Design + Construction  Management of the projects life safety scope and process  Retain consultants Facilities Operations Regulatory Compliance  Statement of Conditions (SOC) - List of known deficiencies  Existing Life Safety Equivalencies/Waivers  Review and comment on life safety documents  ILSM review and checklist  Review and comment Stonehill Taylor Architects as agent for NYP  Current life safety documents  Construction Class  Code basis  Certificate of Occupancy  Review and approval Roles/Responsibilities

9 We Put Patients First Office of Regulatory Planning & Policy Development (ORPPD)  DOH submissions and reviews  Existing licensing status  Existing Waivers A/E Team  Conduct a life safety code analysis of the project limits (fire/smoke compartments) as well the egress to the public way  Develop Required Waivers and / or Equivalencies  Ensure design & construction is according to code taking into consideration best practice (ie. Suites)  Review Existing Conditions and Violations  Record documents based on information from the contractor Contractor  Pre-Construction: Probes, testing, etc.  Pre Construction Risk Assessment (PCRA) Compliance  Post-Construction: “Red line” documents to the AE team in order to create the record documents Roles/Responsibilities

10 We Put Patients First 1.Applicable Projects  DOH Projects  Project limits plus egress path to public way  Non-DOH Projects filed with DOB  Project limits 2.Cosmetic Upgrades  Projects not filed with the DOB  Code analysis is not required  All elements of the project must meet fire and life safety codes and NYP requirements. Life Safety Code Analysis

11 We Put Patients First 1.Obtain current life safety drawings from NYP document library as a reference only 2.Survey existing conditions relative to the life safety drawings 3.Develop revised life safety drawings and code analysis relevant to the current project 4.Submit for review, comment and sign-off by Stonehill & Taylor with each design phase Review and comment by Regulatory Compliance. 5.Revise based on comments 6.Submit record life safety drawings and code analysis electronically to the PM Process

12 We Put Patients First Feasibility  Identify work that will impact cost, schedule, scope in order to develop a project schedule and budget Deliverables 1.Code Analysis  Reconciled matrix of applicable codes/sections including but not limited to:  Occupancy Classification  Exit Stairwells (ie. 50/50 Rule)  Travel Distance  Patient Sleeping/Non-Patient Sleeping Suites  Fire/Smoke Barriers/Doors  Corridor Walls/Doors 2.Existing conditions assessment  Field verification relative to code requirements and current life safety drawings (Note: drawings provided by NYP represent expectations not field conditions. It is the responsibility of the consultant to confirm and determine the scope of work required to meet expectations and modifications to accommodate the project) 3.Life Safety Plan Compliant Suites Process

13 We Put Patients First Schematic Design/Design Development  Confirm conditions and detail documents for cost, schedule and scope verification Construction Documents  Complete life safety and interim life safety documents for agency submission Construction Phase  Compliance with hospital’s PCRA procedures Post Construction  Record life safety documents  DOH Pre-Occupancy Survey Process

14 For Our Patients