Accreditation

Avoid fire drill citations with new matrix

Accreditation Insider, September 6, 2016

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Several months ago, Virginia Mason Medical Center (VMMC) in Seattle was denied full Joint Commission accreditation, in part due to its handling of fire drills. The facility received its citation for failing to vary the times and days when drills were conducted.

Now, The Joint Commission has released a new fire drill matrix for facilities to forestall confusion on survey day. The matrix tracks the day, date, time, and shifts when fire drills are conducted to ensure that they were conducted according to Joint Commission and CMS regulations. While they’ll still examine fire drill forms, surveyors will also give a copy of the matrix to hospitals when they arrive; although you can download an Excel copy of it here. 

The accreditor requires facilities to hold fire drills at random times to ensure that staff are ready when an actual emergency happens. Jim Kendig, The Joint Commission’s field director for surveyor management and development, said in a press release that hospitals are often unaware that they are conducting fire drills at similar times and days. The matrix helps them notice any patterns in scheduling that otherwise might escape notice. 

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



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