FOCUS on EC.02.03.05


In hospitals and other health care facilities many occupants lack the ability to get up on their own and leave during an emergency.  Patients with limited mobility or cognitive challenges, those confined to beds, and patients on vital monitors or life support, those who are incapable of self-preservation, need special consideration during a fire or other life safety situation.  The impracticality of completely evacuating health care facilities has led to decades of advancements in fire safety systems that allow people to remain safely within the building during an emergency.  This defend-in-place approach has a long history of success in preventing injuries and deaths in health care facilities but is also dependent on key, yet complex, systems such as fire alarm and suppression systems.


A review of the 2014 Joint Commission Survey data indicates key areas of noncompliance to Standard EC.02.03.05—lack of inventory, insufficient documentation, standard not provided in documentation, and incorrect duration. For this standard, the issues and risks associated with noncompliance are similar across each of these areas, and those issues and risks are outlined on this webpage (see below).  For specific mitigation strategies and resources for each area of noncompliance, visit the following links: 



Proper design, installation, operation, testing and maintenance of fire alarm and suppression systems are vital to the defend-in-place concept.  Without these systems properly notifying occupants and suppressing a fire event at the point of origin, catastrophic outcomes could result.  Since many patients are incapable of self-preservation and cannot respond to an emergency fire alarm systems providing proper notification is vital to help staff to respond in a timely manner.  By using compartmentalized construction and fire suppression systems fire and other emergency events can be contained at the point of origin and limit the exposure and risk to the rest of the patients and occupants of the building.


In times of fire events or other life threatening emergencies within a structure evacuation from the building is the best option yet with occupants that are physically incapable of self-preservation and others who may have limited cognition abilities to be able to follow basic instructions or make decisions regarding their personal safety a defend-in-place strategy is appropriate.  This type of strategy is dependent on the three areas of fire protection, active fire protection, passive fire protection and fire prevention.  The failure of any of these areas increases the risk of harm to those incapable of self-preservation.  Fire alarm and suppression systems are key components of active fire protection providing early notification, suppression of fire and containment of the smoke and other by products of fire.  The failure to properly maintain and test these systems significantly increases the risk to those who cannot take action on their own.


Fireside Chat on EC.02.03.05, with ASHE Executive Director Dale Woodin, CHFM, FASHE, and Joint Commission Director of Engineering George Mills, MBA, FASHE.


Hospital leadership discussion on EC.02.03.05 with ASHE Executive Director Dale Woodin, CHFM, FASHE, and Joint Commission Director of Engineering George Mills, MBA, FASHE.

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