ILSM Fire Drills

Q: I’ve been conducting two fire drills per month while we are under construction. I am new to the safety role and my understanding of the code is that I should be doing 2 per quarter each on different shifts. My facilities guy says 2 per month. Who is correct? I think we are giving our employees alarm fatigue.

A: Fire drills must be conducted as follows for healthcare occupancies (i.e. hospitals) and ambulatory health care occupancies (i.e. ASC):

  • Regular fire drills must be conducted once per shift per quarter, with start times staggered by 2-hours on fire drills conducted on the same shift but on consecutive quarters;
  • ILSM fire drills must be conducted once per shift per quarter in areas affected by the impairment requiring the ILSM fire drill. This drill is in addition to the regular fire drill.

The ILSM fire drill must evaluate each departments response that is affected by the impairment that requires the ILSM fire drill. This may mean you will have more than one ILSM fire drill per shift per quarter.

It appears you are on the right track with 2 fire drills per shift per quarter while the construction is underway. I’m not sure where the facility guy is coming from with the 2 drills per month requirement.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.