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Bridging the Gap: Connecting Hospital Physical Environment and Life Safety Standards
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- Bridging the Gap: Understanding the Interconnection Between the Physical Environment and Life Safety in ACHC Standards for Hospitals
February 11, 2025
From a facilities perspective, protecting patient and staff safety are the hospital’s biggest priority. To ensure this safety, all aspects of the facility must be constructed, arranged, and maintained to meet a range of regulations.
Understanding the connection between ACHC Standards for Physical Environment and Life Safety can help your facilities team work more effectively. In the Physical Environment chapter of the Accreditation Requirements, ACHC is looking for effective management plans for six topics:
- Building Safety.
- Building Security.
- Hazardous Materials.
- Fire Safety.
- Medical Equipment.
- Utility Systems.
These plans establish a structure for overseeing the physical environment. They include risk assessments and mitigations, role assignments, tasks, and timelines for completion. We require that management plans be reviewed and approved annually by an oversight committee and that associated policies to be reviewed and approved at least every three years.
CREATING A MANAGEMENT PLAN
Consider the relationship of the Physical Environment and Life Safety standards as illustrated by a typical management plan.
The fire safety management plan would be structured to include components defined within both sets of standards. For example, look at closely related sections in the two chapters side by side and consider how they inform the fire safety management plan.
| Physical Environment | Life Safety |
| 11.04 Fire Safety Control |
13.01 Means of Egress 13.02 Fire Alarm Systems 13.03 Fire Suppression Systems 13.04 Fire Safety Systems |
- The equivalent Physical Environment standards for Critical Access Hospitals are found in Chapter 3.
- The equivalent Life Safety standards for Critical Access Hospitals are found in Chapter 14.
Standard 11.00.02: Required Plans and Performance Standards – The hospital shall maintain written plans for the following areas:
- Building Safety
- Building Security
- Hazardous Materials and Waste
- Fire Safety Control
- Medical Equipment Management
- Utility Systems Management
Plans are reviewed and approved at least once every 12 months by the organization’s committee that oversees safety in the environment.
Standard 03.00.02: Required Plans and Performance Standards – Under ACHC’s Accreditation Requirements for Critical Access Hospitals, the CAH maintains written plans and performance improvement standards for the following areas:
- Building Safety
- Building Security
- Hazardous Materials and Waste
- Fire Safety Control
- Medical Equipment Management
- Utility Systems Management
Plans are reviewed and approved at least once every 12 months by the organization’s committee that oversees safety in the environment. The annual review is documented.
The CMS Factor
The connections are further emphasized in the CMS state operations manual (SOM). CMS adopted the 2012 editions of NFPA 101 Life Safety Code and NFPA 99 Health Care Facilities Code in 2016. The SOM mentions both of these, and the codes internally reference several additional NFPA codes (see Chapter 2 of NFPA 101 and NFPA 99).
Best practice for hospital facilities teams is to maintain access to the NFPA codes as essential guidance, cross-reference the ACHC chapters when creating management plans, and reach out to your ACHC team whenever questions arise.
A typical fire safety management plan might look like this:
What Is Meant By “Program”?
A program is the overall coordination of policies, procedures, and activities related to a specific function. In this chapter, programs encompass all activities to provide a comprehensive approach to potential or actual environmental risks.
ACHC requires that management plans be reviewed and approved annually by an oversight committee (such as a Safety Committee), and associated policies must be reviewed and approved at least every three years.
The Bottom Line
By understanding the connection between the physical environment and life safety, organizations can effectively manage their overall programs, ensuring that the hospital is constructed, arranged, and maintained to keep safety top of mind and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This holistic approach is essential for creating a safe and supportive environment for patients and staff.
About the Author
Richard L. Parker, MBA, CHFM, FACHE, FASHE, serves as ACHC Associate Director, Life Safety and Physical Environment. Richard has more than 25 years of experience in engineering, construction, security, environmental services, food and nutrition services, patient transport, laundry and linen services, and communications in hospital settings. He is a Fellow of the American College of Healthcare Executives (FACHE) and a Fellow of the American Society for Healthcare Engineering (FASHE), for which he is an active participant in the Arizona chapter.
Accreditation Commission for Health Care, Inc.