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 1961

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. Objectives Establish Roles/Responsibilities
Define which projects require a life safety code analysis
Describe the various life safety elements beyond the typical project envelope
Review the process to prepare and submit life safety plans to NYP
Understand the importance of delivering a code compliant facility

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

8. Roles/Responsibilities
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

9. Roles/Responsibilities
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

10. Life Safety Code Analysis
Applicable Projects
DOH Projects
Project limits plus egress path to public way
Non-DOH Projects filed with DOB
Project limits
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.

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

12. Process
Feasibility
Identify work that will impact cost, schedule, scope in order to develop a project schedule and budget
Deliverables
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
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)
Life Safety Plan
Compliant Suites

13. Process 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

14. For Our Patients