Maintenance of doors – in particular, ensuring that doors that are required to latch do so – is a problem area for many organizations. Doors fail to latch for many reasons, perhaps the door latch is broken or needs to be adjusted, or perhaps the latch has been taped so that it cannot be latched. Staff may need to be educated about the importance of door latches in isolating patients and staff from fire and smoke while emergency personnel respond to the situation. An organization can successfully manage door maintenance by performing rounds daily, weekly, monthly, quarterly, semi-annually, and annually. The organization may wish to identify its high-traffic areas and increase maintenance inspection of doors in those areas. A door inspection checklist can be used to standardize the inspection process. The organization could also inventory all doors and sort them by type, for example, corridor doors, smoke barrier doors, and fire-rated doors (nonprotective doors, such as those to patient toilet rooms, could be another category). Doors can be further sorted by criteria, such as level of risk if the door system fails, volume of traffic, history of repairs, and so on. The formalized door inspection should be based on the inventory and level of risk associated with the barrier/enclosure protected by each door. Those doors that are most critical in providing building separation or protection would benefit from more frequent inspections, while seldom-used doors may need only an annual inspection. A thorough and accurate door repair history can help in determining the required frequency of inspection.
In addition, an organization may supplement its door inspection program by evaluating doors as part of its fire drill critique process required under EC.02.03.03, element of performance 5. For example, a corridor door to a patient’s room receives daily use, generally without damage, and may go for an extended period of time before receiving a formal maintenance inspection. However, most fire plans require staff to check on each patient during a fire drill by looking into the room and closing the door (indicating the room was checked). If the door is damaged and does not close, staff should issue a maintenance work order. Smoke doors and means-of-egress fire doors (doors in the corridor that are typically held open with an electromagnet connected to the fire alarm) are required to close when the fire alarm system is activated. These doors also may be added to the quarterly fire drill critique form. Each department could assign someone to check that the doors are closed. To be considered “closed,” fire doors must latch and smoke doors must close with a gap no wider than one eighth of an inch. Note: Definitions of terms (barrier, compartmentalization, fire-rated, means of egress, self-closure, smoke barrier) can be found on the National Fire Protection Association (NFPA) website. (Contact: George Mills, gmills@jointcommission.org)