Standards News & Updates

Fire Drills in the Outpatient Setting

Written by QUAD A | Feb 29, 2024 6:45:24 PM

Safety drills such as fire drills matter to healthcare facilities since they house healthcare personnel and potentially vulnerable patients. These patients may not be able to move independently during an emergency or could injure themselves by doing so. As such, it is important to practice for these scenarios. Although it is generally felt by many facilities that these fire drills are redundant, as a fire code requirement, they are not optional. Repetition is critical to these types of drills, so they become routine for staff and then become a habit so that staff do not have to think twice about what to do during an actual fire event.

The industry standard for the frequency of fire drills in a business occupancy healthcare facility is quarterly or more frequently as required by the county or city fire department or your local fire prevention district. However, specifically for Medicare-certified Ambulatory Surgical Centers (ASCs), Life Safety Code standard K712 requires that fire drills be held at expected and unexpected times under varying conditions, at least quarterly on each shift. 

Each facility must keep documentation that the fire drill was conducted. This documentation must include the drill's date and time, along with the names of the staff members participating in the drill. A complete fire drill also includes role assignment, delegation of duties, and an analysis of the drill (i.e., what went well and opportunities for improvement). Once the analysis has been completed, the results should be used to create additional staff education and provide updates to the facility’s policy and procedures as needed.

Please refer to your local fire authority and the state’s health and safety code to verify any additional requirements. Some local fire authorities or states may have more stringent requirements for fire drills. The most stringent requirement prevails.

Fires can occur at any time in almost any place, in any QUAD A facility, and are serious situations to prepare for. When was your facility’s last fire drill? We are closing in on completing the first quarter of 2024, and there is still time to get your first drill in for the year. Look to see when your last drill was, and if it is time for a drill, schedule it on your calendar so everyone in your facility will be confident about what to do in the event of a fire.


Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.