NFPA Life Safety Code:  enForced Standard

NFPA Life Safety Code: enForced Standard

The Triangle Shirtwaist Factory Fire killed 146 young garment workers and drove the establishment of the National Fire Protection Association Committee on Safety to Life (the Committee), the author and caretaker of today’s Life Safety Code, NFPA 101.

The Life Safety Code, in varying editions, is a national standard for healthcare providers, as compliance is required or referenced in-part by legislation in most states. It is also referenced by the Centers for Medicare and Medicaid Services (CMS) through its Conditions of Participation (CoP) for the Medicare and Medicaid programs and and requirements published by accreditation organizations like the Joint Commission.

Today, compliance with the 2000 edition of the Life Safety Code is a CoP for the Medicare and Medicaid programs, and transition to the 2012 code is expected soon. And because it is a CoP, unlike disaster and public health emergency preparedness, the Life Safety Code is a big deal for those who manage healthcare facilities.

You see, it is the states that are responsible for regulating healthcare providers, and, to date, requiring them to prepare for disasters and public health emergencies gets little more than lip service. Maybe that's because emergency preparedness is not a CoP for CMS – yet. If or when CMS makes preparedness a CoP, states will have not choice but to get on board. You can read more about the status of the proposed rule here.

On the upside, let's give a shout out to the Joint Commission for having the fortitude to publish an emergency management chapter in 2009 that contains elements of performance that accredited members must meet. Here, Joint Commission has chosen to lead rather than follow CMS. Unfortunately, they are the lone rangers.

There are other accreditation bodies we'll leave unnamed that choose to ignore the issue altogether, yet are considered 'deemed' organizations by CMS. That will undoubtably change if/when the Proposed CMS Emergency Preparedness Rule publishes as final.

Until such time, preparedness will never be considered on par with 'life safety.' Yeah, a tornado wiping out a hospital is not a 'life safety' issue on par with a fire.


The NFPA was founded in 1896 by a group of insurance firms for the purpose of standardizing the installation of fire sprinkler systems. Yes, escalating economic losses absorbed by the insurance and underwriting industry – not loss of life – was the initial impetus for the NFPA's formation.

Right or wrong, much like disaster preparedness today, it takes a business case to drive economic investment in something that might happen. I mean, would healthcare providers live by the Life Safety Code if they were not forced into compliance by state laws or CMS CoPs? To a certain extent, I'd like to think the answer is yes.

But, would it be the priority it is today? Likely not.

Note that the NFPA is not the maker of laws or the enforcer of codes and standards. It is a nonprofit association that creates and maintains private, copyrighted, standards and codes that can be adopted and enforced by any Authority Having Jurisdiction (AHJ).

An AHJ can be a state or local government, an agency such as the Center for Medicare and Medicaid Services (CMS), or an accreditation body like The Joint Commission.

Before moving on, let’s take a brief look at how the NFPA moved from an organization built on economics to one of human cause.


When the NFPA was founded in 1896, the problem at hand was conflagrations that were destroying entire cities, not necessarily fatalities in individual buildings. The use of highly combustible exterior building materials and the absence of fire sprinklers allowed a small fire to spread rapidly from building to building or town to town.

Some of the more notable conflagrations leading up to the NFPA's establishment include:


Historic Conflagration Fires Timeline Image


By the early 1900s, NFPA codes and standards had been widely referenced in state and local code, all but eliminating conflagrations. Through the more frequent use of use of sprinklers, standardization of fire apparatus and hydrant hose connections, and the use of less combustible external building materials, the NFPA’s work had proven its value. The business case for fire prevention and suppression had been confirmed.

But, as technology evolved, so did the animal that the NFPA had worked so hard to tame.

Death By Design

If the 1800's were the era of conflagrations that destroyed entire cities, the 1900's were the era of structure fires in factories, schools, theaters, night clubs, hospitals, and nursing homes that killed numbers of people never thought possible in a single building.

As the 1900s progressed, it became clear that the NFPA codes and standards that helped municipalities halt the spread of fires from structure to structure did not translate to the protection of people assembled within in the 'modern' buildings being constructed.

As America urbanized, structures became taller, square footage increased, and occupancy levels rose. And the bigger and taller trend was on a collision course with new technologies, making people more vulnerable to the threat of fire than ever before.

As mentioned earlier, the Triangle Shirtwaist Fire – a high-rise fire in a 'modern' building – was a game-changer. The fire, which erupted at the close of the workday, in the heart of America’s largest city, was witnessed by hundreds from the street below that watched helplessly as young women, unable to escape, leaped to their deaths – as exterior fire escapes collapsed, taking people with them.

Now, make no mistake, there had been other catastrophic structure fires leading up to the Triangle Shirtwaist Fire, but none shocked the Nation’s conscience as it did. Maybe, much like Hurricane Katrina, it was the very public display of the human suffering and loss of life that compelled action. Yes, it’s hard to watch people die.

The ominous trend gnawing at the association’s soul included:

  • Iroquois Theatre Fire, Chicago, Illinois, 1903 – 605 killed
  • Rhoads Opera House Fire, Boyerstown, Ohio, 1908 – 171 killed
  • Collingwood School Fire, Collingwood, Ohio, 1908 – 173 killed
  • Triangle Shirtwaist Factory Fire, New York City, 1911 – 146 killed
  • St. Johns School Fire, Peabody, Massachusetts , 1915 – 21 killed
  • See the full interactive timeline here

Historic Structure Fires Timeline Image

It was the study of the aforementioned fires led the Committee to publish standards that addressed:

  1. The construction of stairways and fire escapes
  2. Fire drills in various occupancies
  3. The construction and arrangement of exit facilities for factories, schools and other occupancies

And the first publications that would address the standards were Outside Stairs for Fire Exits, published in 1916 and Safeguarding Factory Workers from Fire in 1918. Both standards were rolled into the Building Exit Code in 1927.

The Building Exit Code would later become the Life Safety Code, NFPA 101, arguably the most effective life safety standard ever developed. And it all started with one catastrophic fire in 1911.

So when will there be a disaster that proves the business case for healthcare preparedness? Wasn’t Hurricane Katrina supposed to do that? Superstorm Sandy?

A Forced Standard

Anyone can write a standard, but it would mean little if it were never adopted and enforced. I mean, what if no state, municipality, agency, or accreditation body referenced and enforced the provisions of the Life Safety Code? Yes, we’d still be killing hundreds in fires in hotels, schools, theaters, night clubs, nursing homes…

But we’re not. Why? Because NFPA 101: Life Safety Code is not only an excellent standard, but it has been and continued to be forced and enforced by AHJs. It seems that there is a business case to be made for fire prevention, detection, and suppression. And people just can't accept dying by fire.

So, why are AHJs not referencing and enforcing NFPA 1600: Standard on Disaster/Emergency Management and Business Continuity/Continuity of Operations Programs?

Huh? The what?

Well, apparently, in 1991 the NFPA Standards Council established the Disaster Management Committee, which published the first edition of NFPA 1600 in 1995. Now, maybe I’ve been asleep at the wheel, but my first inkling that the NFPA had such a standard was when I read a recent article in the New York Times, Can Health Care Providers Afford to Be Ready for Disaster?

The article is about the proposed CMS Emergency Preparedness Rule and its potential effect on healthcare providers. When I read it, what struck me more than anything – beyond the fact that the NFPA actually has an emergency management standard – is that the association is voicing concerns about the proposed rule.

Finally, ten years after Katrina, CMS is acting to make preparedness a CoP for Medicare and Medicaid participating providers and suppliers and the ‘life safety people’ at the NFPA are sticking a wrench in the already slow federal sprockets?.

Regardless of intent, in doing so, they appear to be part of an alliance trying to run out the clock on the publication deadline (December 2016).

In the article, Robert Solomon, a division manager for building and life safety codes at the NFPA was quoted as saying, “[t]here was a lot of opposition to what they proposed.” The article goes on to state that the NFPA had developed its own disaster-emergency management standard and has urged the CMS to defer to it (NFPA 1600).

Now, whether Solomon’s position has merit or not – and there is reason to question how NFPA 1600 could possibly address the nuances of medical surge, inter-facility transfer, memorandums of understanding, and 1135 waivers – seeing NFPA working against the proposed rule is disturbing.

There's a big difference between stating that NFPA 1600 should be referred to wherever possible and stating that it should be deferred to altogether.

Hey, and let’s face it, NFPA 1600 is unlikely to ever see adoption anywhere near that of NFPA 101 Life Safety Code.

Unfortunately, there’s simply not a strong enough business case for it. What's good for people rarely trumps what's good for the bottom line.

bParati seeks to connect healthcare providers, public health, and emergency management through healthcare coalitions. To be notified when we publish, you can follow me on LinkedIn and sign up for our eNews.

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Karl Schmitt, MPA

Karl Schmitt, MPA

Karl is the Passionate Founder & CEO of bParati. He is on a mission to build a national network of effective, sustainable healthcare coalitions. More...

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