At many hospitals, testing of the fire alarm and extinguishing systems is conducted by outside contractors with detailed test reports provided to the hospital. During the past ten years, we have conducted mock surveys at hospitals around the country helping them prepare for accreditation surveys. The following is a list of common problems we find and some suggestions for improvement.

  1. Discrepancies found during testing are repaired at the time of discovery and indicated as “passed” on the inspection report. As an example, while reviewing a test report for the required annual testing of fire alarm audio visual devices, we noticed that although there were several hundred devices tested, the test report indicated that every device passed the test. In a later discussion with maintenance staff, we were told that several strobes had failed and had to be replaced during the testing. The test report needed to indicate that the device test failed, a repair was completed, and the device was re-tested and then passed the test. Hospitals need to work with testing firms to make sure that every discrepancy found during testing is documented, repairs made, and re-testing completed and documented.
  2. Discrepancies are found and documented during testing but there is no documentation indicating the repair was completed. It is very important that hospitals “close the loop” on any deficiency found during required testing. You should be able to explain any delay in completing the repair (e.g. had to order parts) and provide documentation that the repair was completed in a timely manner and the system was re-tested to verify proper operation. This documentation could be as simple as adding a note on the original report indicating the date of the repair, re-testing, and a work order number, if applicable. This recommendation also applies to other required system testing such as medical gas systems and emergency power systems.
  3. Life safety deficiencies found and no life safety risk assessment conducted. Any time a life safety deficiency is discovered and not immediately corrected, a life safety risk assessment must be performed. If a life safety deficiency is found by a contracted testing firm or by in-house staff, the hospital must be aware of the deficiency found as soon as possible so that the risk assessment can be performed and documented.
  4. Delays in receiving the test report. Although a detailed, well-organized report is needed, there is occasionally a significant delay before the final test report is received. As mentioned previously, it is very important that the hospital be aware of any deficiencies found as soon as possible – preferably the same day. Contractors should be instructed to provide a “pencil copy” report to the hospital at the end of each day indicating any deficiencies found. The hospital can then evaluate the deficiency and take appropriate action.

As we strive to make our hospitals as safe as possible for our patients, visitors, and staff, it is critical that required system testing be performed as scheduled and any deficiencies corrected as soon as possible. Timely, accurate documentation is an important part of this process.

Written by: Tom Stewart, Senior Consultant, MSL Healthcare Partners