Hospital fire drill matrix assists code compliance

For years, fire drills and the required varying criteria have been a thorn in the side of facilities management teams. Some larger hospital systems are fortunate to have a compliance team to help ensure that fire drills meet all the criteria and that the drills are effective. Some hospitals even have remedial training for those involved in drills that don’t meet the hospital’s standards. However, at many smaller critical access and rural hospitals, this responsibly falls under the jack-of-all-trades facilities manager. 

There is still some ambiguity over the definition of “quarterly,” but The Joint Commission is actively working to resolve this. As a best practice, the American Society for Health Care Engineering (ASHE) recommends using 90 days from the date of the last event +/- 10-day criteria. However, one of the most difficult criteria to plan for is the varying time between fire drills to ensure that the drill is unexpected and cannot be anticipated. 

For years it was implicitly understood that the expectation of varying times must be greater than one hour between quarters, but one hospital met this criterion as indicated by the data below, and they were still cited: 

First shift — first quarter on Jan. 14 at 10:10; second quarter on April 17 at 14:15; and third quarter on July 12 at 10:40. 

The hospital clearly met the quarterly criteria and varied the drills more than an hour between quarters, so why did the citation occur? The surveyor stated that the hospital did not vary drills greater than one hour between all drills within the past four to six quarters and deemed that this pattern could be predicted. 

The hospital accepted the citation but, to get further clarification, posed the scenario to the central office for official interpretation for future drills. The official response to the scenario/question was “This would be scored as there is not a one-hour difference between all drills.”