Hospital Fire Safety Audits in High-Risk Settings

Consultivo Blog | Impact Stories

Explore how Consultivo’s detailed hospital fire safety audits transformed three large hospitals (high-risk, high-rise healthcare settings), emphasising notable efforts and areas of improvement for enhanced fire and life safety.

In this pivotal project, Consultivo undertook a comprehensive fire safety audit at large Healthcare Centres in India, aiming to enhance safety protocols through a global lens of fire and life safety risk. This impact story delves into the challenges faced, innovative solutions deployed, adherence to international standards of fire and safety in hospitals, and the significant value created for the client.

Key Points

  • Comprehensive Assessment: Consultivo’s assessment covered the entire premises and operations of the Healthcare Centre, employing a detailed methodology based on the Consultivo proprietary Fire Safety protocol AagniSafe, with elements customised for hospitals and healthcare units.
  • Strategic Approach: The assessment protocol AagniSafe (Healthcare), derived from legal requirements, national and international codes, standards, guidelines and industry best practices, provided a risk-based, quantified evaluation of fire safety in hospitals. 
  • It served both statutory safety audit requirements and as a foundation for continuous safety improvement.
  • Elements Considered: The audit focused on five critical elements, including fire safety management, statutory obligations, prevention and protection systems, and training and emergency preparedness.
  • Noteworthy Efforts: Acknowledging the hospitals’ commendable efforts, the report highlights achievements that demonstrate good risk control measures. 
  • Areas of Improvement: The report identifies specific gaps and recommends actions.

Navigating the complexities of a high-rise healthcare facility posed substantial challenges. The expansive scope, encompassing the entire premises and high-risk operations & activities, demanded a meticulous approach. The assessment methodology, based on the 5 elements of the Consultivo proprietary Fire Safety protocol AagniSafe, required in-depth investigation, documentation, and evaluation of risk criticality.

Consultivo’s strategic approach involved developing a customised assessment protocol AagniSafe (Healthcare) aligned with global best practices. The protocol, derived from legal requirements and industry benchmarks, not only met statutory safety audit needs but also laid the foundation for continual safety improvement. 

A team of skilled professionals, employing a risk-based, quantified evaluation, meticulously assessed elements such as hospital fire safety management, statutory obligations, prevention systems, protection systems, and training.

Standards Used for Fire Safety Audit in hospital
Adhering to international standards, Consultivo ensured a precision-aligned audit. The evaluation incorporated globally recognised protocols such as Indian National Building Code NBC 2016, Indian standards (BIS) related to hospital fire and safety, NABH standards, NFPA 99 – Fire Protection Requirements for Healthcare Facilities, IFC guidelines for Fire and Life Safety in healthcare facilities,

The meticulous approach included recommendations based on industry best practices practices.

How we conducted the Hospital Fire Safety Audits as an External Firm

As an external fire safety audit firm, navigating the challenges of a hospital audit requires a proactive and tailored approach. Here are some key considerations to ensure a successful and impactful assessment:

Pre-Audit Planning for Hospital Fire Safety

  • Gather information: Thoroughly reviewed the hospital’s layout, evacuation plans, existing fire safety documentation, and incident history.
  • Risk assessment: Identified potential fire hazards specific to the hospital, such as medical equipment, oxygen tanks, and flammable materials.
  • Stakeholder engagement: Scheduled meetings with key personnel like hospital administration, fire wardens, and staff from different departments to understand their roles related to hospital fire and safety and concerns.

Audit Execution

  • Flexibility and sensitivity: Our audit schedule and methodology was well planned and flexible enough to minimise disruptions to patient care. We utilised non-invasive techniques like hospital fire safety document review and interviews where possible.
  • Specialised expertise: Considered bringing in team members with specific knowledge of hospital operations and fire safety measures in hospital to ensure a comprehensive assessment.
  • Clear communication: Maintained open communication with hospital staff throughout the audit process, explaining our findings and recommendations in a clear and concise manner.

Focus Areas – Hospital Fire Safety

  • Infrastructure: In line with National Building Code or NBC fire safety norms for hospitals
  • Compliance with legal requirements: Hospital fire and safety rules, regulations, norms, NOC, regulatory advisories etc.
  • Evacuation plan review: Analysed the existing ERDMP including evacuation plan for its effectiveness, considering patient mobility, staff roles, and potential bottlenecks.
  • Active fire protection systems: Inspect fire alarm systems, sprinklers, and fire extinguishers for proper functionality and maintenance.
  • Passive fire protection systems: Assess the fire resistance of walls, doors, and compartmentation measures to ensure they can contain a fire.
  • Staff training and awareness: Evaluate the adequacy of hospital fire and safety training for staff and identify any gaps or areas for improvement.
  • Documentation and record keeping: Review the hospital’s fire safety documentation for completeness and accuracy, ensuring compliance with relevant regulations.

Post-Audit Reporting and Recommendations

  • Detailed report: Provided a comprehensive fire and safety report outlining findings, observations, and recommendations for improvement. We prioritised critical issues and offer practical solutions.
  • Implementation plan: We collaborated with the hospital to develop a clear action plan or hospital fire and safety plan for implementing the recommended improvements, including timelines and identifying responsible parties.
  • Ongoing support: Offered ongoing support and guidance to the hospital as they implement the recommended changes.

Additional Considerations for Fire Safety in Hospitals

  • Cybersecurity: We assessed the potential fire risks and control measures (particularly, instrument and equipment controls connected with web) associated with the hospital’s digital infrastructure and recommended appropriate safeguards.
  • Regulatory compliance: Ensured that our audit methodology aligns with relevant fire safety codes and regulations in India.
  • Building relationships and buy-in: Engaging with hospital staff, we communicated findings, addressed queries, and ensured trust and support for the successful implementation of our recommendations.

By adopting a meticulous and collaborative approach, external fire and safety audit firms can play a crucial role in safeguarding hospitals and their occupants from potential fire hazards.

Value Created in terms of hospital fire safety

The impact story extends beyond compliance, emphasising the value Consultivo brought to the Healthcare Centre and hospitals. 

Recognising significant initiatives, our recommendations targeted aligning with fire safety norms, nbc fire safety norms for hospitals, regulations and best practices, contributing to the establishment of a world-class healthcare environment in the hospitals.


This transformative journey exemplifies Consultivo’s commitment to elevating hospital fire safety in high-risk settings. 

By integrating global best practices, the fire safety audits not only addressed immediate challenges but also positioned the Healthcare Centres on a trajectory of safety excellence and continual improvement.

Lessons learnt

Effective communication, flexibility, and a deep understanding of the unique challenges related to fire and safety in hospital are key to conducting a successful and impactful hospital fire safety audit.

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Category:  Blog

Tags: Safety, Fire Safety

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