Offsite Fire Drills

Q: We have a building that is a business occupancy with the exception of two ambulatory care units. I know we have to do fire drills four times a year because of this. One of the ambulatory care units is on the second floor and the other unit is on the main floor in a different wing. If we drill a location other than one of the ambulatory care units, do we need to have someone at each ambulatory care unit also? Or if we drill one ACU do we also need someone at the other one? And do we just observe the staff, or we required to ask the staff all the fire drill questions each time? We are Joint Commission accredited.

A: According to the accreditor’s standard EC.02.03.03, EP 4, it requires staff who work in buildings where patients are housed or treated to participate in drills according to the hospital’s fire response plan. Here is what that EP means:

  • The building that you mentioned is a combination business occupancy and ambulatory care occupancy, therefore it qualifies as a building that treats patients, and this EP applies.
  • The EP only requires staff to participate in fire drills according to what your fire response plan says they should do in the event of a fire. So, they should do something, depending on whether or not the source of the alarm is in their area or not.
  • If the source of the alarm is in their area, then they must follow your fire response plan, which is often referred to as R.A.C.E. That means they must rescue anyone in harm’s way; activate the alarm; close the doors; and extinguish or evacuate, depending what your plan says. If the source of the alarm is not in their area, then they probably just close the doors, which is part of the fire response plan, too.
  • How are you going to ensure your staff participated according to your fire response if you do not have someone observing them? You can post observers in various compartments to watch the staff’s response, the building’s response and the fire alarm system’s response. But, there are other methods, such as self-observation, which requires a manager or supervisor to fax in a report that self-analyzes their level of participation. I’m not a big fan of self-analysis, as they tend to forget to send in the fax and they often times embellish their report.
  • Keep in mind there is no direct requirement to have observers in various departments during fire drills. There used to be, but that standard was removed years ago. But the question a surveyor may ask is how do you know that your staff is participating? This can be done via spot checks, and self-reporting, or posting a couple observers in various departments, and move them around so you catch all departments in a 12 month period.

So, the bottom line is… Yes, you have to have some sort of observation to ensure staff participated in the drill, but the standard does not dictate how many departments need to be observed or how often. That is left up to you to decide. Also, Joint Commission’s hospital standards apply in offsite locations where hospital departments are located, even if those offsite departments are not healthcare occupancies.