September 08, 2016 | | Comments 2
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Avoid fire drill citations with new matrix

Several months ago, Virginia Mason Medical Center (VMMC) in Seattle was denied full Joint Commission accreditation, in part due to its handling of fire drills. The facility received its citation for failing to vary the times and days when drills were conducted.

Now, The Joint Commission has released a new fire drill matrix for facilities to forestall confusion on survey day. The matrix tracks the day, date, time, and shifts when fire drills are conducted to ensure that they were conducted according to Joint Commission and CMS regulations. While they’ll still examine fire drill forms, surveyors will also give a copy of the matrix to hospitals when they arrive; although you can download an Excel copy of it here. 

The accreditor requires facilities to hold fire drills at random times to ensure that staff are ready when an actual emergency happens. Jim Kendig, The Joint Commission’s field director for surveyor management and development, said in a press release that hospitals are often unaware that they are conducting fire drills at similar times and days. The matrix helps them notice any patterns in scheduling that otherwise might escape notice.

“It becomes apparent,” Kendig said. “Hospitals can use this ahead of time, see patterns, and self-correct.”

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Filed Under: AccreditationJoint Commission Changes

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About the Author: Brian Ward is an Associate Editor at HCPro working on accreditation, patient safety, and quality news.

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  1. Steve, what exactly are TJC and CMS expecting when they review the fire drill matrix? I mean, I vary the time of drills on the same shift by at least 3 hours from one quarter to the next, so I’m comfortable with the time separation. But am I going to have a problem if over the course of 5 quarters two day-shift fire drills were conducted on a Tuesday (while the other three were on different days of the week)? Thanks in advance for whatever assistance you can provide.

  2. Hi Steve,
    Short answer: Having two 2/5th of your drills on a Tuesday shouldn’t be a problem, provided they don’t happen at the same time of day. For example, if have a Tuesday drill at Noon, make sure the next Tuesday drill happens either in the morning or later at night.
    To further break up the pattern, you can separate the two Tuesday drills with other days of the week. For example:

  3. Tuesday Noon
  4. Saturday Evening
  5. Tuesday Morning
  6. Monday Morning
  7. Friday Evening
  8. I highly recommend using the Fire Drill matrix in this article to help prevent making patterns.

    And remember, TJC and CMS say that there can’t be a predictable pattern for conducting fire drills, but drills conducted no closer than one hour apart are acceptable.
    Hope this helps, and if you have more questions feel free to reach out again!

    Brian

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