New fire drill matrix can help prevent Joint Commission findings


Subject Matter: Article | Topics: Codes and standards

By Deanna Martin, ASHE Membership and Communications Director

The Joint Commission is asking hospitals to use a new fire drill matrix to track when fire drills were conducted in an effort to ensure they comply with Joint Commission and Centers for Medicare & Medicaid Services (CMS) requirements to hold drills under various conditions (times and days).

Joint Commission surveyors are giving the matrix to facility managers when first arriving for a survey, asking that it is completed by the first or second day of the survey. The matrix is available on the ASHE website so that hospitals can proactively complete the matrix, track their fire drills, and work to vary times and dates of drills.

Jim Kendig, the Joint Commission’s field director for surveyor management and development, said the matrix was created after surveyors noticed that hospitals often conducted drills at the same time but didn’t realize the patterns. Any trends in time and date become obvious once they are all shown on a single chart—for example, if all second shift drills occurred on Tuesdays it would be clear on the matrix.

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

Joint Commission surveyors will still be examining fire drill forms to check that all information on the forms is completed.

Download the Matrix >>