It never really ends, does it…
Concept-wise, this week’s topic is rather limited, but there is a little bit of ground to cover. I am hopeful that this is no news for most of you, but there’s been enough of a recent “run” on survey findings relating to written fire response plans, that I did want to remind folks of the pieces that need to be in place.
So let’s start with the requirements of one accreditation organization (AO)—one with whom you are no doubt familiar—which requires: “The written fire response plan describes the specific roles of staff and licensed independent practitioners at and away from a fire's point of origin, including when and how to sound and report fire alarms, how to contain smoke and fire, how to use a fire extinguisher, how to assist and relocate patients, and how to evacuate to areas of refuge. Staff and licensed independent practitioners (LIP) are periodically instructed on and kept informed of their duties under the plan, including cooperation with firefighting authorities. A copy of the plan is readily available with the telephone operator or security.”
So, if your fire response plan does not specifically outline each of the elements indicated above, then they can (and clearly will) cite you. Most of this is based on this AO’s intent/desire to create as many survey findings as possible, so if it requires digging into the weeds a bit, they are perfectly content to do so.
One of the unfortunate by-products of this survey approach is that it is no longer “enough” to just use RACE/PASS as the bulk of a fire response plan – you can certainly use it as a starting point, but you really have to break it out like this:
- Staff roles at a fire’s point of origin
o When and how to sound and report fire alarms
o How to contain smoke and fire
o How to use a fire extinguisher
o How to assist and relocate patients
o How to evacuate to areas of refuge
- Staff roles away from a fire’s point of origin
o When and how to sound and report fire alarms
o How to contain smoke and fire
o How to use a fire extinguisher
o How to assist and relocate patients
o How to evacuate to areas of refuge
- LIP roles at a fire’s point of origin
o When and how to sound and report fire alarms
o How to contain smoke and fire
o How to use a fire extinguisher
o How to assist and relocate patients
o How to evacuate to areas of refuge
- LIP roles away from a fire’s point of origin
o When and how to sound and report fire alarms
o How to contain smoke and fire
o How to use a fire extinguisher
o How to assist and relocate patients
o How to evacuate to areas of refuge
So, for the purposes of education, etc., you can use the RACE/PASS methodology as the framework, but you need to be able to account for each of the elements. Certainly you can combine regular staff and LIP roles and responsibilities, you just need to be sure that the education processes for each (if they are separate) result in the same level of “knowledge” for folks (I suspect that the “next level” surveying will be to start querying LIPs regarding their knowledge of the fire response plan).
Interestingly enough, the Life Safety Code® does specify the required elements, they just don’t break it out into different groups; NFPA 101-2012 19.7.2.2 requires:
Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
I think these elements are well-represented in the RACE/PASS , though (looking back at the passage above), “cooperation with firefighting authorities” is not necessarily clearly delineated. Might be worth reaching out to your local fire authority having jurisdiction (AHJ) for their interpretation and expectation for that piece of the puzzle. Generally speaking, response to an actual fire event closely follows the Incident Command model in that decision-making defaults to the next “higher” authority until the fire department arrives and then it’s their ball game.
I think I’ve probably yammered enough for now; the findings that I’ve seen relate to there not being a specific accounting of the LIPs in the response plan. You could certainly amend your written plan to include “all staff, including Licensed Independent Practitioners,” but if you go that route, again you need to make sure that you are supporting those groups equally when it comes to providing education and ensuring competency. I have no reason to think that LIPs could or would be interviewed during survey to ascertain their familiarity with fire response plan, so consistency of response to survey queries would probably be useful.
About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is also a contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.