by Brad Keyes, CHSP, on Mar 8, 2021 12:00:00 AM
Q: Currently, I conduct one fire drill per shift per quarter in our hospital for a total of 12 drills a year. I am also required to conduct fire drills in high hazard areas such as MRI, Kitchen, Operating Room, and our Cath OR. If I conduct these drills separately, I will have conducted a total of 16 drills within our hospital for the year. Is there any issue if I incorporated those same four drills as part of the 12 drills for the year?
A: According to section 220.127.116.11 of the 2012 Life Safety Code, fire drills are required to be conducted quarterly on each shift. For a 3-shift facility, that means you need to do a minimum of 12 drills/year. But the intent is not to conduct a fire drill in every department or unit every shift four (4) times per year. If you did, you might be doing 60 or more fire drills a year and that would be awful.
But the intent of the standard is to conduct fire drills to educate and evaluate your staff’s response to an actual emergency. You accomplish this by having observers in departments other than where the drill is initiated. You have to demonstrate to a surveyor that your drills are reaching as many of the staff as possible throughout the year.
You want to make sure you conduct drills in such a way that that all staff are evaluated at least once a year. What about weekend shifts? What about holiday shifts? As you mentioned, you have special units that require additional drills.
I would say trying to incorporate all of the above into 12 drills/year is asking too little. I suspect a good surveyor will be quizzing you on how your 12 drills/year actually evaluates all of the staff at least once during the year.