Q: Is every nursing unit in our hospital required to have one fire drill per shift per quarter? Our Director of Quality says we are required to do so, but that seems too many to me.

A: No, I do not see any LSC requirement or Joint Commission requirement for a fire drill on every nursing unit per shift per quarter. What I do see in the LSC is a requirement for drills to be conducted quarterly on every shift, to familiarize the personnel with the signals and emergency action required under varied conditions (see section 18/19.7.1.2). The purpose of the drill is to test and evaluate the efficiency and knowledge of the staff in implementing your organization’s fire response plan. This can be accomplished by having observers recording the reactions of the staff in compartments away from where the alarm was initiated. The Joint Commission standards on fire drills (EC.02.03.03) are similar in wording and intent. Drills conducted between the hours of 9:00 pm and 6:00 am do not have to activate the fire alarm notification system, as the intent is not to interfere with patient sleep patterns. Other requirements you may be interested in knowing; every time you conduct a fire drill, the fire alarm signal is required to be transmitted so the fire department actually receives notification. Also, no more than 50% of the drills are permitted to be announced. And having the switchboard operator announce overhead “Code Red: This is a drill” every time the fire alarm is activated for a drill constitutes an announced drill, in my opinion. In summary, most hospitals that I visit conduct 12 fire drills per year; one drill on each shift per each quarter. Each drill evaluates the staff’s response in many different locations throughout the hospital utilizing trained observers.

Q: We recently had a consultant advise us to always activate our fire alarm system whenever we conduct a fire drill. We don’t always do that because we perform so many fire drills we think the staff will ignore the alarm when there really is a fire. What do you see as the standard for fire drills?

A: I believe your consultant is correct, with the exception when a drill is performed between the hours of 9:00 pm and 6:00 am. Here is why: Section 19.7.1.2 of the LSC specifically requires the activation of the fire alarm system during drills, along with the transmission of the fire alarm signal. I asked the NFPA to clarify what is meant by the phrase “transmission of the fire alarm signal” and a representative said the intent means to transmit it to the point where you involve everyone in your fire plan. I also asked a representative from CMS how they view the phrase “transmission of the fire alarm signal” and they interpret it to mean the signal needs to go all the way to the fire department for each fire drill. Since the fire department is a large part of your fire response plan, they need to be included. The same section in the LSC also says you do not have to activate the fire alarm system during the hours between 9:00 pm and 6:00 am, as to not disturb sleeping patients. A fire drill is an excellent opportunity to document that the fire alarm transmission signal was received by the local fire department, even if you contract through a vendor to monitor your fire alarm panel. You are required to do so anyway, every quarter. Make sure you document it on your fire drill report.

Q: Are we required to conduct fire drills on every unit and in every department once per quarter per shift in our hospital? Are we required to make sure everyone in the hospital participates in the drill? We have some engineering managers at our hospital who say we must conduct fire drills on every unit once per shift per quarter. That can mean over 300 fire drills per year for us.

A: No and Yes. No, you do not have to conduct fire drills on every unit in the hospital per quarter per shift, and yes, staff is expected to participate in the drills. Allow me to explain: Section 19.7.1.2 of the 2000 edition of the Life Safety Code (LSC) says fire drills must be conducted in hospitals, quarterly on each shift. It does not say anything about drills that must be conducted quarterly on each shift for each department. Section 19.7.1.2 goes on to say drills are conducted to familiarize personnel (such as nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions. That is another way of saying staff must participate in the drills. Joint Commission (and other accrediting organizations) has similar language in their standards found in EC.02.03.03. Where people sometimes become confused, is in the language that requires everyone to participate. Well, for the most part, everyone does participate (or should participate) every time there is a fire drill. Those closest to the area where the alarm is initiated follow the acronym for the hospital’s fire plan, which is frequently R.A.C.E. They Rescue, Active the alarm, Confine, and Extinguish (or Evacuate). But those individuals away from the area where the alarm is initiated also participate, but usually the only requirement in R.A.C.E is to Confine the area by closing the doors. Your organization may have other fire response plans for those individuals to respond to the scene of the alarm with a fire extinguisher. So, everyone on that shift participates (supposedly) in one single fire drill, and you can confirm their participation by having observers in strategic areas making sure they closed the doors.

Q: How would you define unannounced when it comes to fire drills? There doesn’t appear to be anything in the standard that explains what this means. What do you say?

A: The standard you are referring to is the Joint Commission Environment of Care standard, which limits unannounced drills to no more than 50% of all drills. This is not a life safety issue as the Life Safety Code does not address it. In lieu of asking Joint Commission what they meant, I would define announced fire drills as having a published schedule of future drills which is shared with others. Another example of announced drills is having the switchboard operators announce overhead “This is a drill” when the fire alarm is activated. The reason announced drills are undesirable, is staff will react less than optimally when they know the fire alarm is only a drill.

Q: Do we have to conduct a fire drill in every department and unit at least once per shift per quarter throughout our hospital? Some staff is telling me that unless we do so, we are not meeting the Joint Commission requirement for fire drills. Is this true?

A: No, you do not. This is a frequently misunderstood aspect of the Joint Commission standard EC.02.03.03. The performance elements of this standard say fire drills must be conducted once per shift per quarter in each building (not each unit) that is defined as a healthcare occupancy. Where the misunderstanding comes in is the requirement for staff to participate in fire drills in buildings where patients are housed or treated, in accordance with the hospital’s fire response plan. At the source of the fire alarm staff has multiple requirements, but on units and floors away from the origin of the fire, there is little for staff to do other than close doors and be on alert. You may ‘spot-check’ your staff’s participation on units away from the origin of the alarm by having observers make note of the staff’s reaction. These observers may be individuals from your safety committee, or they may be managers of their respective departments.

Q: I am new to this position and I am working on updating my management plan on fire safety. Currently it states “The fire department’s Fire Prevention Bureau will conduct at least two fire drills annually”. Is it a requirement to have the local fire department participate in two of our fire drills, annually?

A: No, it is not. The accreditation organizations and CMS do not have standards that require the local fire department to participate in the healthcare organization fire drills. The Life Safety Code and the other NFPA standards do not as well. It may be possible that there is a local or state regulation that requires the involvement of the local fire department in your drills, but there is no accreditation or certification requirement to do so. However, having the local fire department present during fire drills can be a good thing as it creates positive interaction with them. You can never have too much good will with the local fire inspector and his department. But if it is not required, and it becomes a burden to continue to involve them, take it to your Safety Committee and discuss the issue with them. Ask them if it is okay to stop including the local fire department, and see what they think.

Q: We were recently cited by a surveyor for not conducting annual fire drills at our offsite blood draw locations. I have reviewed the Life Safety Code for business occupancies and we have only 4 employees at these offsite locations, which is less than the 100-person threshold required by the LSC to conduct drills. These locations are rented inside commercial buildings. Do you think we have to conduct fire drills at these locations?

A: Yes I do, because your accreditation organization says you have to. I think the accreditation organization standard is very clear: “The hospital must conducts fire drills annually from the date of the last drill in all freestanding buildings classified as business occupancies and in which patients are seen or treated.”  The building you described sounds like a business occupancy, and the act of drawing blood from a patient is certainly ‘treatment’. So, they got you from two different angles. I would agree with the surveyor that a fire drill should have been conducted annually at the draw stations, regardless of their size or number of employees. This is an example where the accreditor’s standards over-ride the requirements of the Life Safety Code. It’s one disadvantage for the hospital having their own staff and quick draw station, rather than sub-contracting it out. The cost to manage the Environment of Care at these offsite locations is extensive, and probably wasn’t considered when the hospital opened them up. A fire drill is not an easy proposition at these types of small locations, situated within another building. The Life Safety Code requires the activation of the building’s fire alarm system whenever a fire drill is conducted. This would have to be coordinated with the building owner.

Q: We are getting ready to complete our fire drill schedule and need clarification. When conducting fire drills how many remote fire zone/smoke areas are required to be observed and findings recorded? We could not find anything specific in the standards that address this.

A: You won’t find the answer in the current edition of the Life Safety Code or the accreditation standards because it isn’t there. It used to be in the standards back years ago, but the requirements to have observers in other zones during fire drills were dropped. What is now required for fire drill observation is generally identified as staff who work in buildings where patients are housed or treated must participate in drills according to the hospital’s fire response plan. That does not mean a fire drill has to be conducted on every unit. It means staff must participate in fire drills according to your fire response plan. Most hospitals use the acronym R.A.C.E. to describe their fire response plan, which requires staff to confine the fire by closing doors. So, if the fire is on the 4^th floor west wing, staff on the 1^st floor east wing can only close doors based on the fire response plan. How do you confirm that staff participated in a fire drill on a particular unit? By sending someone to walk through and observe if they closed the doors. Since the standard does not say all staff must participate in all drills, then I see no reason to have observers in every unit during every fire drill. I see a more realistic approach of having a program of observing every unit at least once per year. Depending on the physical size of your hospital, you might be able to observe every unit once per year with just a couple of observers per drill. So, the bottom line is you still need to confirm that staff participated in the drills, which usually equates to having observers… it’s just that the accreditation standards do not specify how many units need to be observed during a drill.

Q: Joint Commission standard LS.01.02.01, EP 11 requires the hospital to perform an additional fire drill during periods of Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction. This standard goes on to say that the need for additional fire drills is based on the criteria in the hospital’s ILSM policy. Let’s suppose that a hospital has deficiencies in the Life Safety Code that lasts only for two, three, four days or maybe even a week. Would the hospital still be required to perform an additional drill for such a short duration of Life Safety Code deficiency? What if the hospital’s Safety Committee decides to state that as part of their ILSM policy criteria, it won’t conduct an additional fire drill per shift per quarter unless the Life Safety Code deficiency lasts beyond a certain amount of time, say maybe a month. It seems to me that a Safety Officer would be on the hook for an additional drill per shift per quarter if ILSMs are only in place for a week is overkill and would serve only to further desensitize staff to its fire alarm system.

A: Joint Commission’s standard LS.01.02.01, EP 11 is not prescriptive, meaning they choose not to specify when the extra fire drill needs to start to compensate for a certain deficiency. They don’t even tell you which deficiency the extra fire drill is even required. That is left up to you to decided and state in your ILSM policy.

I tend to think like you, in that the extra fire drill per shift per quarter does not make sense for a short-term LSC deficiency. But when is a LSC deficiency short-term and when is it considered long term? Perhaps a better approach is to ask: “When will the extra fire drill per shift per quarter be required?” Once you decide when the extra fire drill is required, that should help you decide how soon you need to implement the extra fire drill.

When I was the Safety Officer at the hospital where I worked, I felt the extra fire drill was needed when an exit was obstructed or the access to an exit was obstructed. The reason I believed this, is when you do a fire drill one of the items you are assessing is that staff knows the proper way to evacuate patients (using simulated patients, of course). If the path is obstructed, they need to know the alternative path and be able to demonstrate that. The extra fire drill should assesse the staff’s knowledge on evacuation routes.

Some LSC deficiencies aren’t as obvious so you need to ask yourself “Should I conduct an extra fire drill for this deficiency?” for all of the possible scenarios of LSC deficiency that you could have. Set up a Q&A for all the potential LSC deficiencies that you may encounter at your hospital, then ask yourself is an extra fire drill necessary. Here is an example:

• Failed fire dampers?                                                   I would say no.
• Obstructed exit?                                                          I would say yes.
• Unsealed penetrations in a fire/smoke barrier?          I would say no.
• Fire alarm pull stations not working?                         I would say yes.
• Smoke detectors not working?                                  I would say no.
• Obstructed access to an exit?                                     I would say yes.
• An inoperative fire pump?                                         I would say no.

Ask yourself: “Would the staff benefit from an extra fire drill if this feature of life safety was not working?” I would say obstructed exits, obstructed access to exits, and inoperative fire alarm pull stations are easy to say ‘yes’ to… but the others? I’m not so sure as I don’t think the staff would benefit from an extra fire drill for an inoperative fire pump, or a failed fire damper. The next question is: “When do I begin the extra fire drills?” Well, if you have defective pull stations or an obstructed exit, you are going to do education and awareness training to the staff affected by these deficiencies. The purpose of the extra fire drill is to assess the staff’s knowledge of these LSC deficiencies after you have conducted the education and training. So, what is reasonable for an obstructed exit? A month after the exit became obstructed? I would say not. Maybe a week after the exit becomes obstructed, but I would say not any more than a week. The sooner the better, as you (the Safety Officer) want to know for sure that the staff knows about the LSC deficiency and takes appropriate alternative action. But this is my opinion, and you need to take this to your Safety Committee and let them offer their suggestions before you finalize your policy. Document this assessment in the form of a matrix, spread sheet or a written narrative in your ILSM policy, and have your Safety Committee review it and approve it. Then the surveyor can only hold you to what your policy says you should do.

Just as a reminder… The extra fire drills for ILSM purposes need to be conducted in the area(s) affected by the LSC deficiency. That means if you have an obstructed exit discharge due to construction, you need to perform the extra fire drills in all areas affected by the deficiency. That may mean you are doing multiple extra fire drills per shift per quarter, until the LSC deficiency is resolved. Also, each fire drill needs to activate the building’s fire alarm system, but during the hours of 9:00 pm and 6:00 am you are not required to activate the audible signals on the fire alarm system.

 Q: Do table top exercises count as a fire drill? We are updating our old policies and traditionally it has been allowed to have tabletops count as a fire drill, as long as half of them were actual Evacuation Fire Drills.

A: No, table top exercises, while they can be very helpful in the planning phase, are not an acceptable substitute in lieu of actually performing the fire drill. The reason why is you are required to perform multiple functions during a fire drill:

• Evaluate staff’s response to a fire situation, both at the point of the alarm and away from the point of the alarm
• Evaluate the building’s response to the fire alarm
• Evaluate the fire alarm’s response to the drill
• Confirm that the alarm signal was transmitted to the fire department during the drill

In short: How are you going to confirm and evaluate all of that if you do not perform the drill?

Actual fire emergencies are usually an acceptable substitute in performing a fire drill, provided you still are able to make all of the evaluation and confirmations. However, that is not easy to do when you and your staff are responding to an actual alarm.

Sorry, but you still must perform the required amount of fire drills in your facility. And by the way, many accreditation organizations have changed the way they define time. The phrase ‘quarterly’ used to mean you could perform the fire drill anytime during the calendar quarter. Now, Joint Commission and HFAP will require you to perform a fire drill 3 months from the previous drill, plus or minus 10 days. That will require more planning and organization on your part.

Q: We have a building adjacent to our main hospital (separated by a two hour fire wall) that is a mixed occupancy.  There are three stairwells that serve this building, but one has been taken out of service for emergency egress due to a large construction project outside. I have been conducting two fire drills per shift per quarter in this particular building for almost two years now and I fear I have fire drilled our employees in that building to the point that they have become desensitized to the fire alarms.  It’s my understanding that the fire drill frequency can be specified in our ILSM policy.  Here’s my thought – I’d like to state in our ILSM policy that any project lasting longer than a year will no longer require additional fire drills.  That is; a whole year’s worth of additional drills is plenty and more drills can actually have a negative impact instead of a helpful one for our fire response efforts.

A: I think your thought process is valid and sound. Conducting too many fire drills does in fact desensitize one to an actual event. Since the accreditation organizations do not specify exactly what your ILSM policy must say, then I agree that you can reduce the number of ‘additional’ drills based on the length of time that the deficiency exists.

However, the accreditation organization will be somewhat suspicious of this action so you need to be prepared. Do a risk assessment identifying the pros and cons of doing additional fire drills for an extended period of time. Have the risk assessment draw a conclusion. Present this risk assessment to the Safety Committee and ask them to review and approve it. Make sure you get the committee’s response into the minutes. If challenged by a surveyor about doing less than the traditional amount of fire drills for ILSMs, then present the risk assessment and a copy of the Safety Committee’s minutes as evidenced of a thoughtful and considerate decision. The surveyor may accept your position and he/she may not. It’s a crap shoot.

On another point… is the stairwell that has been removed from service a ‘required’ means of egress? If there is a chance you can get your architect to deem the affected stairwell is not a required means of egress, then you can declare the stairwell is no longer a required means of egress and ILSM would not be needed. That means since the stairwell is not a required means of egress then blocking off the discharge is not a Life Safety Code deficiency. If you go that route, make sure you get a decision in writing by the architect and run that through your Safety Committee.

Q: We are required to conduct a fire drill every quarter. If I did one on March 22, when is the earliest and the latest dates that I can do the next one?

A: It depends on who your AHJ is. CMS would allow it to be conducted anytime during the quarter so the next drill could be done as soon April 1 or as late as June 30.

HFAP requires 3 months from the previous activity, with the next drill performed during the third month. So 3 months from March 22, is June 22, the 3rd month would be June, so the next fire drill should be conducted anytime in June.

Joint Commission requires 3 months from the previous activity plus or minus 10 days. But they have a different interpretation on how this is calculated: Three months from March 22, is June. Plus 10 days is July 10, and minus 10 days is May 22, so according to their interpretation, the next quarterly fire drill can be between May 22 to July 10.

But be aware: CMS does not like the idea that a quarterly fire drill could be conducted beyond the quarterly time period. Since the March 22 fire drill was conducted during the first quarter, they would want the second fire drill conducted during the second quarter, and July is not in the second quarter.

Q: There is a matrix floating around on the web that describes Joint Commission’s compliance for fire drills. It breaks the quarters down as Q1=January, February, March, and Q2=April, May, June, etc. Does this mean that for a first shift drill last run in April, we can have the next drill run in September and still be compliant, + or – 10 days?

A: No, not for Joint Commission. In their Overview to the Environment of Care chapter in the Hospital Accreditation Standards manual, Joint Commission says quarterly or once per quarter means “every three months, plus or minus 10 days”. Now, I’ve heard Joint Commission engineers say they will allow this to be interpreted as follows: If the drill was conducted on April 15, that means three months from April is July. July plus 10 days means August 10 and July minus 10 days means June 20. So, according to the engineers from The Joint Commission, the window of opportunity is 51 days: from June 20 to August 10. That scenario would apply to any date the drill was conducted in April.

But to be honest, the Overview of the Joint Commission manual doesn’t say that. Other people are interpreting the Overview to mean if the drill was conducted on April 15, then 3 months after that is July 15. July 15 plus 10 days is July 25, and July 15 minus 10 days is July 5. That leaves you with a 20-day window of opportunity. 20 days is significantly less than 51 days, so you will be at the mercy of the surveyor to determine which one they enforce.

But in the past year, CMS has stated unofficially that they do not like any scenario that allows more than 3 months for a fire drill. In other words, they don’t mind the “every three months, minus 10 days”, but they don’t like the “every three months, plus 10 days”.

Q: Somewhere I read that at least 50% of fire drills had to be unannounced. I don’t find that requirement in NFPA Life Safety Code so it may have been a Joint Commission requirement. We use DNV now and announce very few of our drills but I would like to know if there is any such requirement.

A: You are correct in saying that Joint Commission has a standard on this issue, but the Life Safety Code also addresses this as well. Look at section 4.7.4 of the 2012 Life Safety Code. It says drills shall be held at expected and unexpected times to simulate the unusual conditions that can occur in an actual emergency. While this section does not state 50% of the drills have to be unannounced, the assumption is that unexpected equates to unannounced.

Actually, DNV standard PE.2, SR.6 says healthcare occupancies shall conduct unannounced fire drills. So, it appears DNV wants all their fire drills to be unannounced, not just 50% of them. So, it looks like you should be doing all of your fire drills as being unannounced.

Q: I have a question that is still a little fuzzy regarding fire drills. My hospital is partners with a separate clinic. Several of the clinics throughout the community have hospital employees working there (PT, Imaging etc.) but the building is owned by the clinic. Who is responsible for running drills and testing the emergency operations plan? On a side note, some of the clinics are Rural Healthcare Clinics, so the hospital owns the clinic and it operates under the hospitals CMS number but all of the employees are clinic employees not hospital.

A: Yes… I could see where this would be a fuzzy issue for you. Here is how I suggest you address this issue:

• Your hospital has an interest in the clinics
• Your hospital has staff that work in the clinics
• Your hospital has patients that receive care in these clinics

Therefore; you are responsible for all testing, inspecting, and maintenance of all the fire-safety equipment, and you’re responsible for all drills (EM and fire), as well as meeting the requirements for management plans, EOPs, and policies and procedures.

An AHJ will very likely determine that since you have staff and patients in these facilities, they must fall under the hospital’s rules/standards for Emergency Management, Physical Environment, and Life Safety. That means you need to have copies of the documentation that all of the fire-safety devices were tested and maintained, and copies of all drills were conducted.

Now… if you have a great relationship with your partner clinic, and they perform all of the testing and inspecting requirements, and the drill requirements, then that is fine. You can use copies of their reports as evidence of compliance. But you still need to include these clinics in your management plans and EOP scope of work.

The bottom line is… as long as you have staff and /or patients in these clinics, then your accreditor will very likely expect that you comply with all of the hospital standards at these off-site locations.

Q: What are the requirement for operating room fire drills per Joint Commission, CMS, and AORN? Are operating room fire drills required to evacuate patients?

A: I cannot speak to what AORN suggests for fire drills, but keep in mind their standards are voluntary since they are a professional organization and not an authority having jurisdiction. On the other hand, CMS and Joint Commission’s standards are regulatory compliance and they are not optional; you must comply with them.

Joint Commission says the following under standard EC.02.03.03 for fire drills:

• Drills are conducted once per shift per quarter in buildings defined as healthcare occupancy
• Drills are conducted quarterly in buildings defined as ambulatory health care occupancy
• Evacuation of the patients during the drill is not required
• In buildings leased or rented by the hospital, drills are only required in the areas that the hospital occupies
• In freestanding buildings classified as business occupancies, drills are conducted once per every 12 months
• At least 50% of the drills are unannounced when quarterly fire drills are required
• The conditions for fire drills are varied, and the drills are held at unexpected times
• During fire drills, staff participate in the drill in accordance with the hospital’s fire response plan
• Drills that are conducted between the hours of 9:00 pm and 6:00 am may use an alternative method to notify staff instead of activating the audible alarms of the fire alarm system
• After the drill, the drill must be critiqued to evaluate the fire safety equipment, the fire safety building features, and the staff’s response to the drill. This evaluation must be documented.

CMS refers to the Life Safety Code, and in addition to the above, section 19.7.1 of the 2012 Life Safety Code says the following:

• Fire drills in healthcare occupancies must include the transmission of a fire alarm signal
• Fire drills in healthcare occupancies must simulate emergency fire conditions
• Bedridden patients are not required to be moved during drills

All of the above would apply to any and all drills conducted at the healthcare facility, including those conducted in the operating rooms.

So, to answer your specific question, for fire drills in an operating room, the above regulations would require you to do the following:

• Conduct fire drills in operating rooms and ensure that staff participate in the drill in accordance with your fire response plan. This may mean they are engaged in a drill that originates in their particular room, or perhaps the drill originates in another room, but they must respond to the drill. Their response may very well be different.
• The drill must include the activation of the fire alarm system. This is a requirement. If the drill is conducted between 9:00 pm and 6:00 am, the audible notification devices (horns, bells, chimes) may be silenced.
• The drill must include simulated conditions. This can be a pretend fire in a waste container or an electrical pretend fire. Some organizations use a revolving red light to simulate a fire condition.
• At least 50% of the drills are unannounced. This means you cannot page “Code Red – This is a drill” during the drill, since that announces it is a drill.
• Simulated patients must be moved to another smoke compartment during the drill. If relocating the simulated patient in the OR is not feasible due to the simulated surgery in progress, then alternative action must be taken to protect the patient.
• Observers are needed to critique the response of the staff, the response of the fire alarm system, and the response of the building’s fire-safety features. The LSC and the Joint Commission standards do not say where you observe and how many observers you have, but logic dictates that you need to observe where the simulated fire is at, and in other compartments. How many other compartments? There is no direction on how many other compartments so you get to decide.
• The fire drill critique must be documented, and the expectation is the summary of the drill is reported to the Safety Committee.

However, Since CMS adopted the 2012 edition of NFPA 99, they are now enforcing the new requirement for fire drills in OR surgery found in section 15.13.3.10.3 of NFPA 99-2012, which requires annual fire drills in operating rooms and surgical suite locations.

Q: Our hospital has several “out buildings” or offsite Doctor’s offices. Are we required to do fire drills at these offices? Three of our buildings have fire alarm systems that are tested semi-annually. But we weren’t sure if we were supposed to conducting fire drills at these doctor’s offices or how often they need to be done to be in compliance?

A: Generally, yes… fire drills are required once per shift per year at offsite business occupancies, but it has much to do with your accreditor, or any other authority who enforces the Life Safety Code. Physician’s offices are typically classified as business occupancies and section 39.7.2 of the 2012 LSC says fire drills are only required in business occupancies where the building is occupied by more than 500 persons, or if there is more than 100 persons above or below the street level. So, from a LSC stand point there may be an exception to not conduct fire drills if your physician’s offices are under the 500/100 person threshold.

However, you still have to consider what your accreditation organization requires. For instance, Joint Commission standard EC.02.03.03, EP 2 requires annual fire drills in all business occupancies. Other accreditation organizations, state agencies and local municipalities may have the same requirement. So, it is likely that you do have to conduct annual fire drills.

Q: For clinics that are listed as business occupancies is there a requirement to activate the fire alarm system (chimes and strobes) and send a signal to a third party during a routine fire drill? We have documented staff participation with each drill. The building fire alarm system including communication with the third party is also completed during the year per standard. The clinic (business occupancy) may be located in a building with many other types of businesses.

A: I don’t think so. If you look at the healthcare occupancy chapter section 18/19.7.1.4 (2012 LSC), it says fire drills shall include the transmission of the fire alarm signal. However, there is no comparative section in chapters 38 & 39 for business occupancy. Since the business occupancy chapter does not specifically require the activation of the building fire alarm system for a fire drill, then I would say it is not a Life Safety Code requirement. It would be best practice, but not a requirement.

Sections 38/39.7.2 (2012 LSC) says fire drills in business occupancies (where required) must comply with section 4.7. Section 4.7 discusses many requirements regarding fire drills but activating the fire alarm system is not one of them. Please review your accreditation standards to determine if they require activation of the fire alarm system during a fire drill in a business occupancy.

Q: There is a matrix floating around on the web that describes Joint Commission’s compliance for fire drills. It breaks the quarters down as Q1=January, February, March, and Q2=April, May, June, etc. Does this mean that for a first shift drill last run in April, we can have the next drill run in September and still be compliant, + or – 10 days?

A: No, not for Joint Commission. In their Overview to the Environment of Care chapter in the Hospital Accreditation Standards manual, Joint Commission says quarterly or once per quarter means “every three months, plus or minus 10 days”. Now, I’ve heard Joint Commission engineers say they will allow this to be interpreted as follows: If the drill was conducted on April 15, that means three months from April is July. July plus 10 days means August 10 and July minus 10 days means June 20. So, according to the engineers from The Joint Commission, the window of opportunity is 51 days: from June 20 to August 10. That scenario would apply to any date the drill was conducted in April.

But to be honest, the Overview of the Joint Commission manual doesn’t say that. Other people are interpreting the Overview to mean if the drill was conducted on April 15, then 3 months after that is July 15. July 15 plus 10 days is July 25, and July 15 minus 10 days is July 5. That leaves you with a 20-day window of opportunity. 20 days is significantly less than 51 days, so you will be at the mercy of the surveyor to determine which one they enforce.

But in the past year, CMS has stated unofficially that they do not like any scenario that allows more than 3 months for a fire drill. In other words, they don’t mind the “every three months, minus 10 days”, but they don’t like the “every three months, plus 10 days”.

A recent question by a reader asked if fire-rated doors and smoke compartment barrier doors that close on a fire alarm could be opened before the fire alarm is considered ‘all clear’. The Life Safety Code (LSC) does address certain key actions required by staff during a fire drill, but it does not specifically restrict the use of doors in fire or smoke compartment barriers while the fire alarm is activated. Section 18/19.7.1.1 of the 2012 LSC requires the healthcare occupancy to have a written plan for the protection of all persons in the event of a fire; for the evacuation to areas of refuge; and for the evacuation of the building when necessary.

Section 4.7 of the same codes also makes similar statements regarding orderly evacuation during a fire drill. It makes sense that opening and closing doors in a fire or smoke compartment barrier would be necessary in order to evacuate patients to another smoke compartment, or to evacuate the building. It also makes sense that responding emergency personnel (both internal and external) would have to open and close doors in order to assist with the evacuation or address the fire.

But perhaps what the reader was referring to is the action of the people who are not responding to the fire alarm, and they are going about their regular activity. Doctors, nurses, technicians, visitors, volunteers, vendors, and others may be ignoring the fire alarm and just continue to walk through doors to other parts of the building. These may be the people who the reader was referring to that are opening and closing fire and smoke compartment barriers doors during a fire alarm.

The Joint Commission standard EC.02.03.03, EP 4 says staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan. This is a little bit more than is required by section 18/19.7.1.2 of the 2012 LSC, which says employees of healthcare occupancies shall be instructed in life safety procedures and devices. A fire drill is certainly one method of instruction in life safety procedures and devices. But neither the Joint Commission standard (and EP) and the LSC reference actually requires all staff to participate in every fire drill. It just wouldn’t be practical in a healthcare facility that is providing treatment and care to patients. Business must continue even during a fire alarm, so some staff must continue with their assigned responsibilities.

Therefore, hospitals get to decide for themselves how their staff should react during a fire alarm, as stipulated in their fire response plan (also known as the Fire Safety Management Plan). Most hospitals that I have had the pleasure of working with require staff in the immediate area of the fire emergency respond by following R.A.C.E. (Rescue; Alarm; Contain; and Evacuate or Extinguish) and staff away from the origin of the alarm simply close doors and be ready to receive patients. Some hospitals have staff away from the origin of the alarm to dispatch one individual with a fire extinguisher to the scene of the alarm.

You can write into your plan what you want your staff to do. If you want them to stop at each closed door and not traverse through it until the ‘all-clear’ is given, that is your decision, but I don’t think that is a very practical idea, or one that would be followed. When a fire alarm is activated, it represents a potential disaster and even though it may seem that an ‘all-hands-on-deck’ call is needed, that is not the practical thing to do as a first response. If your facility has 1200 workers on the average day shift, and the fire alarm is activated in the 4^th floor ICU, you do not want all 1200 workers to rush up to the 4^th floor ICU; that is not practical.

The concept of fire response in a healthcare occupancy is all healthcare workers are trained in the facility’s fire response plan. You count on the staff in the immediate vicinity of the fire to respond appropriately and quickly. Once the alarm is announced, certain trained individuals rush to the area where the alarm originates. The rest of the staff is supposed to reply in accordance with your fire response plan. Quite honestly, unless the staff has specific duties during a fire alarm, moving about the hospital performing their normal duties in areas away from the alarm would be considered appropriate. You actually need the hospital to continue to function even during a fire drill. Each fire drill will not asses every staff member’s response; it just is not practical in such a large setting. That is one reason why there are so many fire drills in a hospital each year: By sheer quantity you hope to get nearly all of the staff to participate in at least one drill.

Another issue is physicians. What should they do during a fire alarm? Many hospitals are writing into their fire response plan that physicians on a nursing unit that are not actively providing care or treatment to a patient, should report to the nurse’s station and await direction. In a Surgery department, unless the operating room is the scene of the fire, you pretty much want surgeons and nurses to remain in the operating rooms and continue with the business at hand, and wait for further instructions from the surgery nurse’s station.

I don’t know if I’ve helped the reader with his question, but if it were me, I would let people do what they normally do, unless they have specific responsibilities during a fire alarm. If the reader is really concerned about certain fire or smoke compartment barrier doors being opened in close proximity to a fire, then it would be practical to station one person at the door preventing unauthorized individuals from opening that door.