With over 50 percent of acute care and critical access hospitals coming up short in fire safety standards in 2014, The Joint Commission (TJC) has published easy-to-understand tips on how to comply with the standards focused around the proper maintenance of fire extinguishing equipment. Specific requirements regarding fire pumps, standpipe systems, and automatic fire-extinguishing systems in a kitchen are covered in detail.1

For automatic sprinkler systems: Every 12 months, the organization tests fire pumps under flow. The completion date of the tests is documented. Note: For more information, see NFPA 25, 1998 edition.
This test evaluates the fire pump, the electric motor or diesel engine, and its ability to deliver fire protection water at zero flow (minimum), 100 percent flow (100 percent of the pump’s rating), and 150 percent flow (peak). To do this, attach the flow testing device to a connector on the building so you can measure discharged water. If you use a bypass flow meter, remember to periodically calibrate the flow meter. Next, evaluate the flow from the pump and the pump’s performance, including suction and discharge pressures. Check for proper operation of installed alarms and installed relief valves. If an electric motor is connected to emergency power, test the automatic transfer by a simulated normal electrical power loss while the pump is delivering peak output. If it’s a diesel engine, document speed and water, as well as oil temperature indicators and oil pressure, to ensure that it is operating correctly. Make adjustments if deficiencies are identified. Compare results to previous tests to identify system degradation by using a performance (graphic) curve of pressure versus flow or review written data.

Every five years, the organization conducts water-flow tests for standpipe systems. The completion date of the tests is documented. Note: For more information, see NFPA 25, 1998 edition.
This EP pertains to the installed hose system, not to the fire sprinkler system. For a wet system (water is always in the pipe), verify that the water supply provides adequate design pressure and flow. For a dry system (water is not released into the pipe until it’s needed), test the dry standpipe for leaks, and perform the flow test for design pressure and flow. Water discharge should be from the most hydraulically remote point (typically the rooftop) to properly validate design pressure and flow. Large buildings have multiple zones with pressure-reducing valves that will require separate water discharging at the most hydraulically remote point for each zone.

Every six months, the organization inspects any automatic fire-extinguishing systems in a kitchen. The completion dates of the inspections are documented. Note: Discharge of the fire-extinguishing systems is not required. For more information, see NFPA 96, 1998 edition.
Organizations that have a cooking area or facility that produces grease-laden vapors, must have a commercial fire-extinguishing system that is either automatically triggered by fusible links or manually activated via a pull station. Either of these systems can immediately put out a cooking surface fire. The system must be inspected twice a year, without discharging the single-use extinguishing media during the evaluation. This inspection confirms that, when activated, the system will shut off the natural gas or electric fuel source to the burner and trigger the building’s fire alarm system. The test also validates that hood fans operate as designed to efficiently remove smoke and exhaust. Check that overhead nozzles are pointed at the cook surface and clean any grease buildup on the overhead hood. Once a year, replace the fusible links and document this change.


With the proper fire safety protocols and training, your facility can create a safe environment for patients and staff, and quality patient care is dependent on a safe and environment. How do your fire policies stack up against those of other facilities? provides healthcare facilities with benchmarks in order to compare their policies to a comprehensive backdrop of local, national, and international regulations and best practices.




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