Joint Commission aligns fire drill requirements with NFPA

Effective immediately, Joint Commission (JC) has eliminated the requirement for organizations to space each quarterly fire drill by at least one hour from the previous quarterly fire drill. Additionally, JC-accredited organizations are no longer required to conduct quarterly drills within a 10-day window of the previous drill. These revisions were made to align with the requirements of the National Fire Protection Association’s NFPA 101-2012®, Life Safety Code®, adopted by the Centers for Medicare & Medicaid’s Conditions of Participation.

NFPA 101 requires that, “Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.”

For years, the accrediting organization went beyond these requirements to require JC-accredited organizations to space each quarterly drill by at least one hour from the previous quarterly drill and requiring the drill to be done within a 20-day window. The updated standard reflects the code language which does not specifically define quarterly, but refers to Merriam-Webster's Collegiate Dictionary, 11th edition, as the source of undefined terms. That source defines quarterly as “recurring, issued, or spaced at 3-month intervals.”

The Joint Commission has emphasized that fire drills must still be unannounced, occur at unpredictable times and take place under varying conditions. Health care and ambulatory occupancies must continue to conduct one drill per shift each quarter.

The updates will appear in the March 1update of the accreditation manuals, specifically in Physical Environment Chapter 03.01.01, Element of Performance 3, for hospitals and critical access hospitals.