According to the Joint Commission Environment of Care standard EC.02.03.03, hospitals must conduct regular fire drills to routinely assess their fire safety plan, equipment, building features, and medical staff response. Developing a tested and tried procedure is one of the most critical steps to protecting your building and the people inside. Pushing it off could result in violations, fines, and danger for all persons involved. 

At LMC, our team is prepared to help guide you through fire safety steps so you know exactly what to expect.

Hospital Fire Drill Process

Hospitals don’t require a full evacuation due to the size, nature of the facility, and difficulty in transporting patients. Even so, it’s crucial to establish a plan so that patients, staff, and visitors know where they should or shouldn’t go in the event of a fire.  

Fire drills ensure your staff remains confident in safely removing patients from harm's way while managing the situation with knowledge and haste - so strict adherence and practice are necessary.

What is a Hospital Fire Response Plan?

Your hospital fire response plan should include a general synopsis of what to do in a fire, along with individual roles,  important building features, and all emergency exits. 

These written plans should be accessible to all staff in the hospital, along with the regular practice of activating the fire alarm system, accessing fire extinguisher systems, notifying emergency responders, and the detailed evacuation drills.

A General Fire Response Plan for Hospitals

A general fire response plan follows the RACE acronym with the additional steps of Relocation and Evacuation to protect patients in a hospital setting.

R - Rescue persons from room or area. 

A - Activate the alarm.

C - Close doors to minimize the spread of fire and smoke. 

E - Extinguish or evacuate.

According to the NFPA and the Joint Commission, hospitals must perform fire drills at least once per quarter for every shift, at varying times of the day, and on varying days of the week.

Hospital Fire Drill Matrix

To improve safety, preparedness, and compliance with regular fire drills, the Joint Commission developed this fire drill matrix:

The Fire Drill Matrix helps assist in the evaluation by allowing facilities to self-identify where they meet hospital fire drill requirements and areas to improve. 

This tool makes it obvious when fire drills are routinely scheduled at the same time. So, they must be spontaneous and unannounced to prevent staff from anticipating them and risk becoming unresponsive when a real fire occurs. 

To ensure fire drills are documented and meet NFPA and Joint Commission EC standards, they can be documented using this matrix, which is then given to the Life Safety surveyor.

Fire Drill Checklist

After each fire drill, the facility should follow a clear checklist to evaluate the effectiveness of the safety protocols. Managers should then look for ways to improve their response times, maintain a calm and efficient atmosphere, and upgrade equipment as necessary.

It’s important to be proactive and cover all your bases when it comes to the safety and security of your building. LMC is well-versed in the protocols and requirements of the Joint Commission when it comes to hospitals and healthcare facilities - contact us today to learn more or find out how we can help make your hospital a safer place.