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See why fire drill critiques draw interest

Accreditation Connection, October 8, 2004

This survey occurred May 19-21 at Santa Rosa Medical Center, a 129-bed, acute care community hospital in Milton, FL.

Seemingly small slip-ups in two standards turned out to be the biggest safety thorns during this visit from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), though the hospital's overall performance led to a positive accreditation decision.

Both problems centered on fire drill actions, though one of the complaints also touched on emergency management and utilities concerns.

"Across the board, it was the same issue: collecting the information needed about staff knowledge" of safety training and policies, says Greg Newchurch, plant manager at Santa Rosa.

This survey was a good example of how surveyors want to gauge frontline staff knowledge. "The focus was on us finding our weaknesses, identifying them, and then correcting them," Newchurch says. "[Surveyors] wanted us to do that with our information gathering techniques, such as with our fire drills."

The hospital received a "requirement for improvement" (formerly a Type I recommendation) for not properly critiquing the activities of staff members during fire drills.

Under environment of care (EC) standard EC.5.30 (fire drills), hospitals must evaluate drills to discover any deficiencies or areas that need improvement.

As a result of the finding, the facility had to submit an "evidence of standards compliance" report to the JCAHO-essentially a written action plan for fire drill critiques-showing how it corrected the violation, Newchurch says.

Know who shuts off oxygen

Another issue was the shutoff of oxygen valves during a fire alarm-specifically, which employees have that responsibility.

"As part of your fire drill, you need to identify who can turn the oxygen off," Newchurch says. Hospitals stumble over this provision because staff who have the authority to shut down medical gas valves may not fully appreciate that the well-being of patients on oxygen is as important as building safety.

When asked, some staff members at Santa Rosa did not know who had the authority to shut down the valves, or even where the valves were located. The JCAHO issued a supplemental finding encompassing EC.5.10 (fire safety plan), EC.4.10 (emergency management plan), and EC.7.10 (utilities plan).

Newchurch quickly tackled the supplemental by making it clearer in safety orientations who has the authority for oxygen shutoff. Direct, related questions for staff will also be part of future fire drills.

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