Your FREE CHFM Flashcards 2026 – 100+ Cards

The NFPA standard that protects building occupants from fire and smoke through egress, fire-rated construction, and occupancy rules; adopted by CMS.

The Health Care Facilities Code — risk-based requirements for medical gas/vacuum, electrical safety, and gas equipment in healthcare occupancies.

The National Electrical Code — the standard for electrical installation, including the essential electrical system and isolated power.

Standard for Emergency and Standby Power Systems — governs testing and maintenance of the generator-based emergency power supply system (EPSS).

National Fire Alarm and Signaling Code — installation, testing, and maintenance of fire alarm, detection, and notification systems.

Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems — sprinklers, standpipes, and fire pumps.

Standard for Safeguarding Construction, Alteration, and Demolition Operations — fire safety during construction in an occupied facility.

Federal requirements a hospital must meet to bill Medicare/Medicaid; the Physical Environment CoP adopts NFPA 101 and NFPA 99 by reference.

When CMS recognizes an accreditor (e.g., The Joint Commission) as proof a facility meets the Conditions of Participation.

The proactive document a hospital uses to manage and track Life Safety Code deficiencies and their correction plans; a key survey artifact.

Temporary, compensating actions (fire watch, signage, training) that keep occupants safe when a life-safety feature is impaired or during construction.

The organization, office, or individual responsible for enforcing a code or standard or approving equipment, materials, an installation, or a procedure.

CMS currently enforces the 2012 edition of the Life Safety Code (and NFPA 99) for healthcare occupancies.

A continuous, unobstructed path of travel from any point in a building to a public way; a core requirement of NFPA 101.

The hospital fire strategy of protecting occupants by moving them horizontally through smoke barriers rather than fully evacuating the building.

Under the 2012 Life Safety Code, a smoke compartment in a new hospital may not exceed 22,500 square feet.

Per NFPA 101 (2012), a fire watch or evacuation is required when a fire alarm system is out of service more than 4 hours in a 24-hour period.

Per NFPA 101 (2012), a fire watch or evacuation is required when an automatic sprinkler system is out of service more than 10 hours in a 24-hour period.

Requires identifying hazardous chemicals, labeling, an SDS for each, and worker training; underpins safe chemical handling in a hospital.

A standardized document detailing a chemical's hazards, handling, and protective measures; must be readily accessible to staff every shift.

Requires an exposure control plan, engineering controls, PPE, and training to protect workers from blood-borne infectious materials.

EPA rules governing how healthcare facilities accumulate, label, and dispose of hazardous pharmaceutical waste.

Sharps and infectious waste that must be segregated, contained, and treated separately from general trash under state rules.

32 inches of clear width is the minimum for doorways accessible to wheelchair users under the ADA.

Requires healthcare facilities to report adverse events (deaths/serious injuries) related to medical device use to the FDA and/or manufacturer.

A risk-based approach (Category 1–4) where requirements scale with the harm a system failure would cause to patients and staff.

When a hospital cannot immediately correct a Life Safety Code deficiency, CMS may grant a time-limited waiver if patient safety is not jeopardized.

A construction document specifying the quantity, quality, and description of materials and work needed for a project.

Identifying all parties affected by a project and their level of influence so the team can plan communication and manage expectations.

A living document that logs identified project risks, their likelihood and impact, owners, and planned responses.

A scheduling technique that finds the longest sequence of dependent tasks, setting the shortest possible project duration; delays here delay the project.

The amount of time a non-critical task can slip without delaying project completion; critical-path tasks have zero float.

A visual bar-chart schedule showing project tasks against a timeline, with start/finish dates and overlaps.

A technique that integrates scope, schedule, and cost to measure project performance and progress against the plan.

A responsibility matrix clarifying who is Responsible, Accountable, Consulted, and Informed for each project task.

Uncontrolled expansion of project scope without adjustments to time, cost, or resources — a leading cause of overrun.

The group that reviews and approves or rejects proposed changes to a project's scope, schedule, or budget.

A traditional delivery method where design is fully completed, then the project is bid and built by a separate contractor.

A delivery method placing design and construction under a single contract, allowing overlap and earlier cost certainty.

A delivery method where a construction manager commits to a guaranteed maximum price and manages the build, joining during design.

A multidisciplinary process matching the type of construction activity to nearby patient risk to set required containment precautions (Class I–IV).

Class I–IV containment levels that escalate with patient vulnerability and the dust/disruption of the construction activity.

A Joint Commission-required assessment of air quality, infection control, utility needs, noise, vibration, and other hazards before construction.

The Facility Guidelines Institute's Guidelines for Design and Construction — the primary U.S. reference most states adopt for healthcare facility design.

The process of verifying that building systems are installed and perform per the design intent and Owner's Project Requirements.

The document recording the owner's functional needs and expectations that drives the design and commissioning of a facility project.

A commissioning document verifying equipment is properly installed and ready before functional performance testing begins.

Routine rounds checking barrier integrity, signage, and fire-safety measures to keep an occupied facility safe during construction.

An updated ICRA process combining the type of construction activity (dust generated) with the risk group of affected patients to set precautions.

A cause-and-effect quality tool used to identify the root causes of a problem in a project or process.

Scheduled, time- or usage-based servicing performed to prevent failure; the compliance baseline, documented in the CMMS.

Condition-based maintenance using monitoring (vibration analysis, thermography, oil analysis) to act only when a fault is developing.

A strategy that assigns the best maintenance approach to each asset based on its function and the consequence of its failure.

Repairing equipment only after it breaks; acceptable only for non-critical, easily replaced assets.

Computerized maintenance management system — software that schedules, tracks, and documents work orders, PM, assets, and inventory.

A predictive technique using thermal imaging to find hot spots in electrical and mechanical systems that signal impending failure.

A predictive technique that detects bearing wear, misalignment, and imbalance in rotating equipment before failure.

A centralized control system that monitors and automates HVAC, lighting, and utilities, reducing manual intervention.

A motor controller that varies fan/pump speed to match load, sharply reducing the electrical consumption of HVAC motors.

An airborne-infection-isolation room kept negative to adjacent spaces so airborne pathogens (e.g., TB) stay contained.

A protective-environment room or operating room kept positive to adjacent spaces so contaminated air does not flow in.

The standard for ventilation of healthcare facilities — sets air changes per hour, pressure relationships, temperature, humidity, and filtration by space.

Per ASHRAE 170, a new operating room requires a minimum of 20 total air changes per hour.

Per ASHRAE 170, an airborne-infection-isolation room requires a minimum of 12 air changes per hour, negative to surrounding spaces.

Minimum Efficiency Reporting Value — rates an air filter's efficiency; higher-acuity hospital spaces require higher-MERV final filters.

High-efficiency particulate air filtration (≥99.97% of 0.3-micron particles) used in protective-environment rooms and other critical spaces.

A documented plan (per ASHRAE 188 / CMS) to control Legionella by mapping the water system, setting control limits, and monitoring temperature/treatment.

The standard for Legionellosis risk management for building water systems; the basis for a hospital's water management program.

A plumbing device that prevents reverse flow and contamination of the clean potable water supply.

Under NFPA 99/110, the three branches are life safety, critical, and equipment; life safety and critical restore power within 10 seconds.

A device that automatically transfers a hospital's load from utility power to the emergency generator within 10 seconds of an outage.

Under NFPA 110, the emergency generator set is inspected weekly to verify readiness.

Under NFPA 110, the generator is exercised under load monthly for at least 30 minutes at a minimum of 30% of nameplate kW.

Per NFPA 110, an extended (3-hour) load test is required every 36 months to confirm the EPSS can carry the load over time.

A valve box located outside a patient-care area used to shut off oxygen or other medical gas to a single zone during an emergency.

Per NFPA 99, area alarm panels monitor medical gas pressure for anesthetizing locations and Category 1 patient-care areas.

A device that protects hospital electrical equipment from damaging voltage spikes and transients.

Arc flash labels/study should be reviewed at least every 5 years or whenever a major electrical system modification occurs.

The recirculation loop is kept at or above ~124°F as part of Legionella control in the water management program.

Applying an artificial load to a generator to verify it can handle its designed load and to prevent wet stacking.

Fire and smoke dampers in hospitals may be tested every 6 years (versus every 4 years in non-hospital occupancies).

Ultraviolet germicidal irradiation used to reduce airborne and surface pathogens, supplementing infection-control measures.

Discounts all future cash flows to today's dollars at the cost of capital; a positive NPV adds value — the preferred capital metric.

The discount rate that makes a project's NPV zero — its effective yield; accept when it exceeds the hurdle rate.

The time needed to recover the initial investment; simple but ignores the time value of money and cash flows after payback.

Net benefit divided by cost, expressed as a percentage; a quick comparison metric with no time dimension.

Total cost of owning an asset over its life — purchase plus energy, maintenance, downtime, and disposal; guides repair-vs-replace.

The full cost of an asset including purchase price and all ongoing operating costs like service contracts and energy.

The plan for long-lived assets and projects above the capitalization threshold; these are depreciated, not expensed.

The plan for recurring day-to-day expenses — labor, utilities, supplies, and service contracts.

A dollar policy (e.g., $5,000) above which a purchase is capitalized and depreciated; below it, the item is expensed.

Allocating an asset's cost over its useful life to reflect loss of value; not a cash outflow since the cash was spent at purchase.

Spreading an asset's depreciable cost evenly across its useful life (e.g., a $500,000 boiler over 20 years = $25,000/year).

An accelerated method recording larger depreciation expense in an asset's early years.

Comparing actual spending to the budget to explain and act on differences (e.g., utility spend over forecast).

A liquidity measure (current assets minus inventory, divided by current liabilities) indicating ability to meet short-term obligations.

Evaluating the financial impact of varying operating assumptions to test a project's sensitivity and risk.

Monitoring cash inflows and outflows to assess a facility's or project's liquidity and financial health.

Comparing the total financial impact of leasing versus purchasing equipment, considering cost of capital, tax, and useful life.

The Joint Commission framework for managing the physical hospital safely across safety, security, hazmat, fire/life safety, medical equipment, and utilities.

Safety; Security; Hazardous Materials & Waste; Fire/Life Safety; Medical Equipment; and Utility Systems — each needs a plan and annual evaluation.

A yearly review of each management plan's scope, objectives, performance, and effectiveness — a required deliverable for surveyors.

The document defining a facility's all-hazards response and recovery; updated at least annually to reflect changes.

A tool that identifies potential emergencies and ranks them by probability and severity to prioritize preparedness; reviewed at least annually.

Mitigation, preparedness, response, and recovery — the all-hazards cycle a hospital's program must address.

A post-exercise or post-incident review documenting gaps and improvements; drives updates to the HVA and EOP.

The interdisciplinary group that receives environmental risk reports, reviews EC plan evaluations, and recommends corrective actions.

Regular tours of the facility to identify safety hazards and compliance issues, with findings reported to the safety committee.

A leadership approach that inspires and motivates a diverse team toward a shared vision — effective for managing facility staff.

A long-range plan aligning the facility's space, infrastructure, and capital investment with the organization's mission and regulatory needs.

Coordinating facility functions and data on one platform to improve interdisciplinary communication and decision-making.

Measurable indicators tracked over time and reported to leadership — e.g., percentage of PM work orders completed on time.

A document providing consistent, repeatable guidance for responding to a situation (e.g., a utility failure), ensuring a uniform response.

For the 2026 cycle, TJC consolidated the physical-environment standards into two chapters: Physical Environment and Emergency Management.

An evaluation of the physical environment (in behavioral health) to identify and remove features a patient could use for self-harm.

Using operational data to improve decision-making — energy optimization, predictive maintenance, and resource planning.

Prioritizing total value and long-term partnership incentives — not just lowest price — when contracting facility services and supplies.