Case Study: EH&E and Brigham and Women’s Hospital Award Winning Program to Advance Life Safety in Healthcare

IFMA_AwardCermony2014_2.0Brigham and Women’s Hospital (BWH) partnered with EH&E on the development of a program to address root causes of fire wall breaches and permit proactive identification and resolution of fire and life safety deficiencies during construction. The program includes a “continuous compliance” program to insure proper procedures are followed during renovation and maintenance activities throughout the life of the building. This new approach was honored for setting a new benchmark for the construction of healthcare facilities and as a model of best practices, receiving the 2014 IFMA (International Facility Management Association) Boston Excellence Award for Best Practices in Sustainability.


This article presents results of the investigation into root causes of firewall breaches and details the program that was developed – and successfully implemented on new construction and renovation projects at BWH – to address deficiencies prior to occupancy and to maintain continuous compliance after occupancy.

Root Cause Investigation of Firewall Integrity Challenges

To address firewall and barrier issues in new construction and maintain the integrity of firewall compartments in all BWH buildings, Stephen Dempsey, Director of Facilities Planning and Construction at Partners HealthCare (the corporate umbrella organization for BWH and its affiliated institutions), convened a multidisciplinary team of in-house and external advisors of construction, fire safety and engineering professionals, coordinated by EH&E.  As the first step, the team conducted a root cause investigation of current practices in construction and operations that resulted in breaches in firewall containment systems.

New Construction Survey

During construction, the complexity of the work and the pace of the schedule can lead to unexpected compromises in the establishment of compartmentalization with firewall barriers. With so many trades installing ductwork, pipes, cables, and wires through conduits and penetrations in walls and floors, improper sealing of these critical points in fire and smoke containment can result. Addressing firewall issues during construction would allow for the costs of repairs to be borne by responsible parties rather than by BWH at a future date.

Existing Building Survey

In existing buildings, constant work by multiple groups including tele/data, contractors providing facility upgrades, and engineering and maintenance performing normal repairs can often cause inadvertent compromises in barrier integrity. Studies have shown a statistical rise in the number of unacceptable firewall penetrations as the use of space evolves through multiple iterations and the density of data networks increases.


The root cause analysis for firewall deficiencies identified the following major issues:

  1. Inadequate coordination between various trades resulting in poor sequencing of work.
  2. A lack of a method for identifying repairs that may create unacceptable penetrations during the life of the building.
  3. Ambiguity amongst various parties as to what constitutes an “acceptable smoke and fire barrier system” and who has responsibility for ensuring it is implemented.
  4. The need for independent oversight to “commission” the final firewall systems.
  5. A simple methodology to effectively track open items requiring correction and document their closure throughout the life of the building.

Financial Modeling of Firewall Deficiencies

Analysis of construction cost data revealed that the average cost to repair fire barrier deficiencies in newly occupied hospital buildings is approximately $700 per issue. Furthermore, studies have shown that the average number of firewall deficiencies in new medical buildings is close to 1 per every 300 ft2 of floor area. This data indicates that a new 360,000 ft2 building would contain approximately 1,200 non-compliant firebarrier deficiencies penetrations upon occupancy. If a more effective firebarrier inspection and repair system was not utilized during construction, the cost to resolve these issues, after occupancy, would approach $1.1 million.

The cost of repairs to correct deficiencies in existing building due to tele/data or routine maintenance can be 25 to 50% higher than that for new construction. This is primarily due to the significant expense incurred in first surveying to find these often isolated deficiencies as well as repair them. Furthermore, the possible disruption of mission-critical work causes significant scheduling and access issues resulting in higher costs.

The financial modeling illustrated that the cost of a “during-construction” firewall inspection program would be substantially lower than the cost of repairing the deficiencies after occupancy. Furthermore, it was clear that implementation of a comprehensive management program for all in-house and vendor trades to ensure the integrity of firebarriers would be financially beneficial.

Implementation of an Information Management Solution and Results

Based on the findings of the root cause analysis and financial modeling, a Construction Life Safety Information Management (C-LIM) system was developed for new buildings and renovation projects. The elements of the C-LIM system include:

  • New construction and renovations: Review work plan for all subcontractors, through the General Contractor (GC), to improve coordination and sequencing of work.
    Provide training and certification for all subcontractors that have responsibility for sealing penetrations and only permit “certified” individuals to do the work.
    Track resolution of all outstanding firewall issues prior to occupancy.
    Link contractors to firewall issues and evaluate their workmanship.
  • Work in existing buildings:
    Implementation of an Above Ceiling Permit Program that provides automated notification of planned above ceiling work, plan for repair, and verification of completed work.
    Ensure that only properly “certified” individuals are performing the repairs.
    Coordinate firebarrier resolution activities undertaken by various internal departments, potentially conserving resources for all groups.
  • Automate field inspections and reporting using tablets and smart phones used by the design and construction management team and parties responsible for repairs or compliance.
  • Provide an executive dashboard for noting site conditions and tracking outstanding and resolved issues.
  • Provide actionable information on contractor performance that can be used to support contract decisions and negotiations going forward.

Successful Implementation of Construction Life Safety Information Management Process

The C-LIM system has been implemented on two new construction projects and multiple renovation projects at BWH in 2013. “This program achieves everything that we had hoped. It improves our construction and maintenance performance and fosters collaboration amongst the teams, provides the documentation to have confidence in our continuous compliance, and maintains budget neutrality when we account for the significant costs avoided in having to address corrective actions after occupancy. This program is a home run for patients, employees, first responders and BWH,” stated Stephen Dempsey, Director of Facilities Planning and Construction at Partners HealthCare.

For the buildings where this new approach was implemented, all outstanding firewall issues were resolved prior to occupancy and an ongoing permit program manages access to the above ceiling space for routine maintenance activities. Re-inspection of the areas where this program has been applied has shown greater than 96% compliance with Joint Commission criteria which is consistent with BWH’s goal of continuous compliance. This will translate into significantly lower repair costs in these buildings in the future.

The use of field inspection technologies and a central, management dashboard with automated email alert capabilities has improved communications and expedited resolution of identified issues. Contractor and sub-contractor access to the management dashboard supports accurate and timely notations and speeds up Requests for Information (RFI).

During the course of developing and implementing this new approach to ensure the integrity of firebarriers, a few valuable lessons were learned including:

  • A detailed review of the firestopping submittals is necessary to determine appropriate and approved systems to be installed.
  • Demonstrations on mockup fire-stopping and firewall barrier installations are recommended for all contractors early in construction to ensure appropriate and approved methods are understood and used for addressing the various penetration issues that may occur.
  • Advance notice and training for contractors on the inspection and implementation program is essential to ensure that owner’s expectations and compliance with quality assurance specifications are met.

The identified causes of deficiencies in firebarriers are not unique to BWH, they are common challenges during construction, renovation, routine maintenance and tele/data upgrades for all healthcare institutions. The proven success at BWH shows hospitals how to cost effectively resolve these issues and how to set the foundation for maintaining continuous compliance of life safety and firewall barrier systems throughout the life of their buildings.

For more information on this program, contact Michael Della Barba, Director Commissioning Services at or at 1-800-825-5343.