PCRA Meetings: Life Safety Considerations

Health Care Facilities that receive their accreditation from The Joint Commission (TJC) are subject to the TJC Standards. These form the basis of accreditation surveys and are intended to provide key performance elements for patient, individual, or resident care and organizational functions so that facilities can provide safe and high quality care.

One of the most critical times to perform a custom evaluation of patient safety within accredited healthcare organizations is during periods of construction. Within the Environment of Care Chapter of the TJC standard the hospital is required to conduct a preconstruction risk assessment (PCRA) to evaluate the impacts to air quality, infection control, utility requirements, noise, vibration, life safety, and other hazards that affect care, treatment and services (EC.02.06.05 EP 2). Given the multi-disciplinary nature of the risk analysis, Hospitals typically form PCRA committees that are staffed by personnel in responsible charge of the various areas of impact. These PCRA committees meet regularly and are required to document their analysis and subsequent approval of all construction activities within the facility.

Life safety is a critical component of a PCRA evaluation. It is paramount that the individual(s) performing the Life Safety evaluation are well versed in impairments of the various life safety systems in the building. Under the umbrella of life safety, impairments to the following systems are included: fire alarm & detection systems, fire protection systems, smoke control system, means of egress, and passive fire protection systems & features (i.e. fire rated walls, doors, and dampers. Furthermore, impacts to first responders should also be included in such evaluations as well as mitigating the risks of increased risks of a fire event inherent with construction (i.e. hot work in areas where combustible materials are stored). If the evaluation done by the hospital finds that the planned work will impair one or more of these systems, an interim life safety measure (ILSM) is required to be implemented for the duration of the impairment(s) based on the hospitals policy (LS.01.02.01 EP1).

Examples of common impairments are:

  • Fire alarm shut down greater than 4 hours
  • Sprinkler impairment lasting greater than 10 hours
  • Reconfiguration of the exit access system
  • Reduction in corridor width
  • Blocked exit
  • Blocked exit discharge
  • Fire rated door removed in rated wall for extended period of time
  • Holes made in fire rated barriers
  • Obstructions to fire lanes

Depending on the complexity of the project, specialized ILSMs that take into account the different phases of the project and number of impairments the project may need to be created.


Application of any information provided, for any use, is at the reader’s risk and without liability to Code Red Consultants. Code Red Consultants does not warrant the accuracy of any information contained in this blog as applicable codes and standards change over time. The application, enforcement and interpretation of codes and standards may vary between Authorities Having Jurisdiction and for this reason, registered design professionals should be consulted to determine the appropriate application of codes and standards to a specific scope of work.