August 11, 2020 | | Comments 0
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I feel like we’ve crossed this bridge before…fire drills are all the RACE!

While the numbers are fairly small (though at almost 30% for a noncompliance rate during 2019 surveys, you could certainly make the case that almost any deficiencies in this area is too much), there remain a couple of common stumbling points when it comes to conducting fire drills. According to the August 2020 issue of Perspectives (get it at your newsstand now!), there continue to be issues with:

  • Not completing/documenting quarterly drills on every shift. I don’t know that there’s a whole lot of mystery here—sometimes you miss a drill. You don’t want to miss a drill; nobody wants to miss a drill! But sometimes the quarter expires so quickly that you don’t realize that a drill was missed until it’s too late. The links below will take you to The Joint Commission’s guidance on the topic, but my best advice is to set a reminder for March 10, June 10, September 10, and December 10 to check fire drill status. That way, you’ve got a couple of weeks if you need to get one in.

https://www.jointcommission.org/resources/news-and-multimedia/podcasts/take-5-the-environment-of-care-fire-drill-matrix-tool/

https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/

  • The fire alarm signal was not transmitted on the third shift drills. I absolutely understand why this is still in the mix (as TJC has noted, the allowance for a coded signal for drills between 9P and 5A, does not preclude the transmission of the fire alarm signal). My best advice is to have a line item on your fire drill critique form that goes a little something like: Fire alarm signal transmitted – Yes   No. That way you are providing a surveyor documentation of the signal transmission where you know they’ll be looking.

https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/environment-of-care-ec/000001235/

  • Not enough variation of times when fire drills are conducted; not too much more to say that hasn’t already been said—you have to mix it up—and make sure that the folks conducting the drills understand that once you’ve set up a fire drill schedule, it is to remain unchanged without approval. I know that sounds kind of draconian (and I suppose it is), but our surveyor friends have been rather inflexible on this count and you don’t want to get dinged for a measly 15 or 30 minutes of overlap in your drill times. In the words of the inimitable Moe Howard, when it comes to fire drills—SPREAD OUT! Or, if you’d rather use George Mills’ take on it, you can find that here (with some other Life Safety bon mots).

Now, at the moment, the survey process is not focusing on fire drills as a function of the 1135 Waivers in effect due to the COVID-19 maelstrom. So it would seem that we have a little bit of time to work on the finer points of fire drill compliance. I think the overarching focus is going to end up being (and I think this is likely to be the case with emergency management exercises) is how well you are doing relative to ensuring that “all staff” are participating. For the purposes of the education and training component, I would like to think that if we can demonstrate that everyone in the organization (including the folks in administration) participated, to some degree, over a two-year period, that will result in a finding of compliance during survey. Is it even possible for most places of size to get to everyone, every year? I’m thinking not, but feel free to disagree. I think it may end up going the route of hazard surveillance round frequency—you have to do as many as you have to do to cover the territory you need to cover. So, if in order to be effective, you have to do more than one fire drill per shift per quarter, then that becomes part of the algorithm used for your annual evaluation (or to use the annual evaluation as a place to ensure your clear assessment of the effectiveness of the program). There is always the potential for a surveyor to disagree with your fire drill schedule, as it relates to effective education of staff. Use the annual evaluation to document your assessment of the effectiveness—it may be the only way to keep the survey wolves away from the flock.

So, let’s get the flock out of here…

As always, hope you are well and staying safe. I’ve been traveling some over the past few weeks and, humans being humans, I think we’ve got a ways to go before we wrestle this thing to the ground, so keep those shields up!

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Filed Under: The Joint Commission

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 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 stevemacsafetyspace@gmail.com.

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