Extra fire drill as part of The Joint Commission’s ILSMs
I fielded a question a little while back about using a fire drill as an interim life safety measure (ILSM) under Joint Commission standard LS.01.02.01 EP 11.
The actual verbiage from the pre-2009 standard was that each organization would conduct a minimum of two drills per shift per quarter, but it did not specifically identify those drills as ILSM drills.
EP 11 currently states an organization may conduct “one additional fire drill per shift per quarter” as an ILSM.
Where I suspect the change came about is that folks would ask whether the requirement was for two drills in addition to the normally required drills (no), or whether the requirement was for one additional drill per shift per quarter for a total of two (one ILSM, one regular), which is what is indicated by the 2009 version.
Interestingly enough, the former note of a “minimum” of two drills per shift per quarter has been removed, so the expectation is that there would be no more than two drills total per shift per quarter.
About the Author: Steve MacArthur is a consultant for The Greeley Company, a division of HCPro. He brings 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at 
